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ABSTRACT  OF  REPORT 


ON  THE 


ORIGIN  ANi)  SPREAD  OF  TYPHOID  FEVER 

IN  U.  S.  MILITARY  CAMPS  DURING 

THE  SPANISH  WAR  OF  1898 


BT 


WALTER  EEED, 

MAJOR    AND    SURGEON,    U.    S.    ARMY, 

VICTOR  C.  VAUGHAN, 

MAJOR    AND    DIVISION    SURGEON,    U.   S.    V. 
AND 

EDWARD  O.  SHAKESPEARE, 

MAJOR    AND    BRIGADE    SURGEON,    U.    S.    V. 


WASHINGTON: 

GOVERNMENT    PRINTING    OFFICE. 
1900. 


TABLE  OF  CONTENTS. 


Introduction 3 

Lei ter  of  transmittal .... .. 5 

Chapter  I. — Typhoid  fever  in  the  First  Division,  First  Army  Corps 11 

II. — Typhoid  fever  in  the  Second  Division  of  the  First  Army  Corps .  13 

III. — Typhoid  fever  in  the  Third  Division  of  tlie  First  Army  Corps.  15 

IV. — Typhoid  fever  in  the  First  Division,  Third  Army  Corps .  _  23 

V. — Typhoid  fever  in  the  Second  Division  of  the  Third  Army  Corps.  26 
VI. — General  remarks  concerning  typhoid  fever  in  the  First  and 

Third  Army  Corps . 35 

VII. — Typhoid  fever  in  the  Second  Army  Corps,  Camp  Alger,  Va. . .  78 

VIII. — Typhoid  fever  in  the  Secotid  Army  Corps,  Camp  Meade,  Pa  __  104 

IX.— Typhoid  fever  in  the  Fourth  Army  Corps 124 

X. — Typhoid  fever  in  other  organizations  at  Chickamauga .   128 

XI. — Typhoid  fever  in  the  First  and  Second  divisions,  Seventh  Army 

Corps .    129 

XII. — Typhoid  fever  in  the  Third  Division,  Seventh  Army  Corps. . .  137 

XIII. — Coincident  malaria  and  typhoid  fever .  147 

XIV. — General  statements  and  conclusions 167 

XV. — The  etiology  of  typhoid  fever 194,^ 


INTRODUCTION. 


The  assembling  of  250,000  volunteer  troops  in  military  camps  within 
a  short  time  after  the  declaration  of  war  against  Spain  in  the  spring 
of  1898  taxed  all  the  bureaus  of  the  War  Department  to  the  utmost. 
The  Medical  Corps  of  the  Regular  Army  was  barely  sufficient  for  our 
little  Army  of  25,000  men.  To  this  corps  of  trained  medical  officers 
were  suddenly  added  115  commissioned  medical  officers  of  volunteers 
and  382  medical  officers  of  State  organizations,  most  of  whom  had  had 
no  previous  military  experience.  Owing  to  the  extensive  prevalence 
of  typhoid  fever  in  our  camps,  it  became  necessary  at  a  later  date  to 
reenforce  this  enlarged  corps  of  medical  officers  by  the  employment 
of  contract  surgeons.  The  number  of  contract  surgeons  in  service 
on  June  30,  1898,  was  151;  July  31,  272;  August  31,  512;  September 
30,  564.  At  the  same  time  the  Hospital  Corps  of  the  Army,  which 
before  the  war  consisted  of  520  privates,  most  of  whom  were  tolerably 
well  trained,  had  to  be  expanded  by  the  addition  of  6,588  recruits, 
who  for  the  most  part  were  entirely  untrained  and  consequently  unfit 
for  the  responsible  duties  of  nursing  seriously  ill  men.  It  therefore 
became  necessary  to  send  to  our  general  and  camp  hospitals  trained 
female  nurses,  whose  services  were  highly  appreciated  by  our  medical 
officers  generally,  and,  indeed,  under  the  circumstances,  were  indis- 
pensable. The  number  in  service  on  June  30,  1898,  was  23;  July  31, 
162;  August  31,  924;  September  30,  1,065. 

The  enormous  task  which  confronted  this  enlarged  Medical  Depart- 
ment is  shown  by  the  fact  that  more  than  20,000  cases  of  typhoid 
fever  occurred  among  our  troops  encamped  within  the  limits  of  the 
United  States  during  the  months  of  May,  June,  July,  August,  and 
September,  1898.  The  causes  for  this  extgnsjye  prevalence  of  a  fatal 
infectious  disease  are  fully  set  forth  in  the  exhaustive  report  made 
by  the  board  of  medical  officers  convened  by  my  request  (Special 
Order  194,  Adjutant-General's  Office,  August  18, 1898).  I  regret  that 
it  is  not  practicable  at  the  present  time  to  publish  this  report  in 
extenso.  It  consists  of  2,600  typewritten  manuscript  pages,  and  is 
accompanied  by  5  maps  and  many  plans  of  camp  sites,  84  graphic 
charts  showing  the  prevalence  of  typhoid  fever,  intestinal  disorders, 
and  malarial  infections  in  the  various  volunteer  regiments,  and  9 
charts  showing  the  meteorological  conditions  prevailing  at  the  princi- 
pal camps  during  the  period  to  which  the  report  relates.     The  repoit 

3 


as  a  whole  will  for  the  present  be  placed  in  the  library  of  the  Sur- 
geon-General's Office,  where  it  may  be  consulted  by  those  desiring  to 
see  the  original  data  upon  which  the  conclusions  of  the  board  are 
based.  In  order  that  these  conclusions  may  be  available  for  the  use 
of  the  profession  at  the  earliest  practicable  date,  the  following  ab- 
stract of  the  report  is  now  published.  I  desire  to  express  my  high 
appreciation  of  the  able  and  painstaking  manner  in  which  the  board 
has  accomplished  the  task  imposed  upon  it,  and  also  to  express  my 
sincere  regret  at  the  death  of  Maj.  Edward  O.  Shakespeare,  surgeon, 
TJ.  S.  Volunteers,  which  occurred  very  shortly  after  he  had  completed 
his  arduous  labors  as  a  member  of  this  board. 

Geo.  M.  Sternberg, 
Surgeon-General  U.  S.  Army. 


LETTER  OF  TRANSMITTAL. 


The  Surgeon-General  U.  S.  Army. 

Sir:  I  have  the  honor  to  forward  herewith  the  report  of  the  board 
of  medical  officers  convened  per  Special  Orders,  No.  194,  Adjutant- 
General's  Office,  August  18,  1898.  In  submitting  this  report,  which 
gives  the  results  of  the  board's  investigation  into  "the  cause  and 
extensive  prevalence  of  typhoid  fever  in  the  various  military  camps 
within  the  limits  of  the  United  States, "  I  desire  to  bear  witness  to  the 
unremitting  labors  of  the  volunteer  members  of  the  board,  Majs.  Vic- 
tor C.  Vaughan  and  Edward  O.  Shakespeare.  Although  honorably 
discharged  from  the  service  of  the  United  States  on  June  30,  1899,  at 
a  time  when  this  report  was  far  from  being  completed,  these  gentle- 
men voluntarily  continued  to  give  their  services  to  the  Government, 
to  the  entire  exclusion  of  their  private  interests;  the  former  until 
January  31,  1900,  and  the  latter  until  the  day  of  his  death,  June  1, 
1900.  Whatever  scientific  value,  therefore,  the  report  of  this  board 
may  possess,  must  be  largely  credited  to  the  untiring  efforts  of  its 
volunteer  members.  I  desire  also  to  call  attention  to  the  invaluable 
assistance  rendered  the  board  during  the  past  two  years,  in  the  prep- 
aration of  tables,  charts,  etc. ,  by  Mr.  C.  J.  Myers,  chief  clerk,  Army 
Medical  Museum. 

Very  respectfully,  Walter  Reed, 

Major  and  Surgeon,  U.  S.  Army, 
President  of  the  Board. 

Special  Orders,  J  War  Department, 

y  Adjutant-General's  Office, 

No.  194.  )  Washington,  August  18,  1898. 

*  M:  *  *  *  *  * 

40.  A  board  of  medical  officers,  to  consist  of  Maj.  Walter  Reed, 
surgeon,  U.  S.  Army;  Maj.  Victor  C.  Vaughan,  division  surgeon, 
U.  S.  Volunteers,  and  Maj.  Edward  O.  Shakespeare,  brigade  surgeon, 
U.  S.  Volunteers,  is  appointed  to  meet  in  this  city  at  the  earliest  date 
practicable  for  the  purpose  of  making  an  investigation  into  the  cause 
of  the  extensive  prevalence  of  typhoid  fever  in  the  various  military 
camps  within  the  limits  of  the  United  States,  under  such  instruc- 
tions as  it  may  receive  from  the  Surgeon- General  of  the  Army.  The 
board  will  call  the  attention  of  the  proper  commanding  officers  to  any 
insanitary  conditions  which  may  exist  at  the  camps  visited  by  it,  and 
will  make  recommendations  with  a  view  to  their'  proper  correction. 

5 


6 

The  report  of  the  board  will  be  forwarded  to  the  Surgeon-General 
as  soon  as  practicable  after  the  completion  of  the  investigation 
contemplated. 

Such  journeys  as  may  be  required  under  the  above  order  are  neces- 
sary for  the  public  service. 


By  order  of  the  Secretary  of  War 


H.    C.    CORBIX, 

Adjutant-  General. 


INTRODUCTION    TO    THE    STUDY    OF    TYPHOID    FEVER    IN    THE 
FIRST.  SECOND,  THIRD,  FOURTH,  AND  SEVENTH  ARMY  CORPS. 

It  will  be  well  to  explain  the  method  pursued  in  the  study  of 
typhoid  fever  in  these  several  organizations. 

In  compliance  with  the  order  convening  the  board  we  visited  and 
carefully  inspected  all  of  the  larger  encampments  in  the  United 
States,  viz,  Camp  Alger,  Va. ;  Camp  Cuba  Libre,  Jacksonville,  Fla. ; 
Camp  George  H.  Thomas,  Chickamauga  Park,  Ga.,  and  Camp  Meade, 
Middletown,  Pa.  We  also  inspected  the  camps  at  Fernandina,  Fla., 
Huntsville,  Ala.,  Knoxville,  Tenn.,  and  Wycoff,  N.  T.  In  making 
this  inspection,  which  covered  the  period  from  August  20  to  October 
10,  1898,  we  endeavored  to  ascertain  by  the  testimonj'  of  medical 
officers,  especially  the  regimental  surgeons,  and  by  direct  personal 
observations  all  the  facts  ascertainable  with  regard  to  the  origin  and 
spread  of  typhoid  fever  in  the  several  commands.  We  acquainted 
ourselves  with  the  water  supply,  the  nature  of  the  soil  of  the  camp 
site,  the  space  allotted  regiments,  the  arrangement  and  size  of  the 
tents  and  the  number  of  men  occupjang  each  tent,  the  disposal  of 
excreta,  the  location  of  sinks  with  reference  to  mess  tents,  the  dis- 
position of  garbage,  the  care  given  to  the  conditions  of  sinks  and 
cesspools,  and  the  thoroughness  with  which  the  camps  were  policed. 
Not  only  did  we  try  to  elicit  all  the  data  obtainable  on  these  several 
points  in  the  larger  encampments,  but  we  were  also  particular  to 
bring  out  all  the  evidence  possible  with  regard  to  the  water  supply, 
the  character  of  the  camp  site,  the  disposal  of  excreta,  and  the  prev- 
alence of  disease  in  the  various  State  encampments.  We  visited 
regimental,  di^dsion,  and  other  hospitals  and  ascertained  the  methods 
of  disinfection  practiced  in  these  hospitals.  In  short,  we  endeavored 
to  see  for  ourselves  everything  that  might  have  a  bearing  on  the 
origin  and  spread  of  tj^phoid  fever. 

Upon  our  return  to  Washington  we  found  ourselves  in  possession 
of  more  than  1,000  typewritten  pages  of  testimony  given  by  medical 
officers,  all  of  which  bore  in  one  direction,  viz,  to  the  conclusion  that 
typhoid  fever  in  our  several  camps  was  due  to  the  contamination  of 
the  water  supply. 


We  next  began  the  study  of  the  records  of  the  Surgeon-Geueral's 
Office.  These  consisted  of  the  reports  of  sick  and  wounded  made  at 
the  end  of  each  month  by  the  regimental  surgeons.  In  the  study  of 
the  regiment,  which  we  have  taken  as  the  unit,  we  have  first  carefully 
examined  the  monthly  sick  report  made  by  the  surgeon  in  charge. 
After  a  thorough  study  of  the  regimental  records,  we  have  gone 
through  the  division  and  general  hospital  records,  and  have  endeav- 
ored to  trace  as  fully  as  possible  the  history  of  every  prolonged  ill- 
ness in  the  regiment,  especiallj^  those  of  intestinal  origin  or  of  a 
febrile  character,  no  matter  under  what  diagnosis  recorded.  We 
have  made  a  special  effort  to  determine  when  the  first  case  of  typhoid 
fever  appeared  in  the  regimenl.  In  doing  this  we  have  given  the 
date  of  the  first  case  of  "probable "  typhoid  fever  and  that  of  the  first 
case  of  "recognized"  typhoid  fever.  Of  course,  in  many  instances 
these  dates  are  the  same,  because  the  first  case  of  probable  typhoid 
fever  was  recognized  as  that  disease.  In  the  case  of  the  First  and 
Third  Army  Corps  we  have  made  from  the  regimental  records  a  list, 
including  the  name,  rank,  and  company,  of  every  man  who  was  sick 
ten  days  or  longer.  After  doing  this  we  have  taken  the  hospital 
records  and  ascertained  as  far  as  possible  the  disposition  of  each  of 
these  cases.  In  the  case  of  the  First  and  Second  divisions  of  the 
Second  Army  Corps  and  the  Second  and  Third  divisions  of  the  Seventh 
Army  Corps  we  have  copied  out  the  name,  rank,  company,  and  regi- 
ment of  every  officer  and  soldier  sick  with  any  germ  of  intestinal  or 
febrile  disease. 

We  have  followed  these  through  regimental,  division,  general,  and 
State  hospitals,  and  have  ascertained  the  duration  of  the  attack  and 
any  changes  in  diagnosis  that  might  be  made.  In  32  regiments  of  the 
Second  Army  Corps  and  in  16  regiments  of  the  Seventh  Army  Corps 
we  have  traced  the  subsequent  history  of  every  enlisted  man  having 
a  short  diarrhea  or  supposed  mild  malarial  attack,  in  order  to  see 
whether  these  individuals  afterwards  showed  any  immunity  to  typhoid 
fever.  Having  endeavored  to  ascertain  with  every  degree  of  accu- 
racy within  our  power  the  number  of  cases  of  typhoid  fever  in  118 
regiments,  we  found  that  the  data  were  more  or  less  incomplete  in  20. 
Of  the  remaining  98  regiments  we  have  charted  by  company  and  regi- 
ment 84.  In  60  of  these  regiments  all  cases  of  typhoid  fever,  all  short 
and  long  malarias,  and  all  diarrheas  are  indicated  on  the  charts 
according  to  the  date  of  their  occurrence.  Of  the  remaining  24  regi- 
ments only  cases  of  typhoid  fever  are  charted. 

Bearing  on  the  possibility  of  infection  by  personal  contact,  we  have 
endeavored  to  locate  by  tents  and  in  the  order  of  their  occurrence 
everj'-  case  of  typhoid  fever  which  developed  in  a  number  of  regi- 
ments of  the  Second  and  Seventh  Army  Corps,  especially  in  the  Fif- 
teenth Minnesota,  Thirty-fifth  Michigan,  Two  hundred  and  third  and 
Two  hundred  and  first  Xew  York,  and  Second  New  Jersey  Volunteer 


Infantry.  These  data  were  furnished  largely  by  the  medical  officers 
of  these  regiments,  and  in  part  by  the  captains  of  15  companies  of 
regiments  belonging  to  tlie  Second  and  Seventh  Corps. 

It  will  be  readily  seen  that  in  prosecuting  this  work  we  have  assumed 
a  task  not  only  of  great  magnitude  but  one  beset  with  manj^  difficul- 
ties. The  incompleteness  of  regimental  medical  records,  the  changes 
in  the  spelling  of  names,  the  giving  of  initials,  and  the  statement  of 
rank  and  company  have  given  us  no  end  of  trouble.  However,  we 
have  spared  no  pains  and  we  believe  that  we  have  not  duplicated 
cases.  In  the  case  of  men  who  were  furloughed  we  have  carefully 
searched  the  reports  of  mustering-out  officers;  and  in  ascertaining 
the  names  of  those  who  have  died  and  the  cause  of  death,  we  have 
resorted  to  the  records  of  the  Adjutant-General's  Office.  Many  men 
were  sent  home  on  hospital  trains  and  were  distributed  in  civil  hos- 
pitals throughout  the  country.  The  medical  officers  of  these  hospitals 
have,  as  a  rule,  been  kind  enough  to  send  us  detailed  reports  giving 
the  name,  regiment,  rank,  company,  diagnosis  and  termination  of  each 
case.  In  a  few  instances  hospital  officials  have  refused  to  make  such 
reports,  hence  we  have  not  secured  reports  from  all  the  civil  hospitals. 
However,  in  some  of  these  institutions  in  which  the  superior  officers 
have  refused  to  suj)ply  us  with  the  desired  information  physicians  in 
immediate  charge  of  patients  have  at  considerable  sacrifice  of  time 
made  out  the  desired  lists  for  us.  To  all  of  these  we  wish  to  express 
our  warmest  thanks.  We  are  particularly  indebted  to  Maj.  David 
C.  Peyton,  surgeon,  U.  S.  Volunteers,  for  complete  reports  of  sick 
from  the  various  State  and  city  hospitals  of  Pennsylvania. 

Ha^dng  ascertained  when  the  first  case  of  typhoid  fever  appeared 
in  each  regiment,  we  have  endeavored  to  trace  the  progress  of  the 
disease  and  to  account  when  possible  for  its  spread.  Especial  atten- 
tion has  been  given  to  the  effects  of  the  movements  of  regiments,  the 
sites  of  camps,  the  water  supply,  and  the  disposition  of  fecal  matter 
upon  the  spread  of  the  disease. 

It  will  be  seen  that  we  speak  of  "recognized"  or  "certain"  and 
"probable"  cases  of  typhoid  fever.  The  recognized  or  certain  cases 
need  no  comment  nor  explanation.  By  "probable"  we  refer  to  cases 
which  were  not  recognized  by  any  of  the  military  medical  officers  as 
typhoid  fever,  but  which  we  believe  to  have  been  cases  of  this  disease. 
We  have  kept  these  two  classes  distinct  in  order  that  our  statistics 
may  not  be  vitiated  by  our  own  ideas.  When  we  began  the  inspection, 
of  camps  and  hospitals,  we  soon  saw  that  manj^  medical  officers  were, 
in  our  opinion,  failing  in  the  recognition  of  typhoid  fever.  Immedi- 
ately we  asked  the  Surgeon- General  to  send  to  each  encampment  an 
expert  properly  equipped  to  make  blood  examinations  for  the  Plas- 
modium of  malaria  and  to  apply  the  Widal  test  for  typhoid  fever.  It 
is  to  be  regretted  that  these  examinations  were  not  begun  earlier. 
However,  we  have  been  able  through  these  experts  to  clear  up  the 
diagnosis  in  a  large  proportion  of  the  cases.     In  many  places  our 


9 

report  will  apparentlj^  be  a  reflection  upon  the  professional  skill  of 
the  medical  officers.  This  reflection  is,  however,  more  apparent  than 
real.  We  wish  to  testify  to  the  fact  that  the  medical  officers,  both  in 
the  volunteer  and  the  regular  service,  were  men  of  more  than  average 
professional  ability.  It  is  true  that  weak  men  were  found  in  both 
lines  of  service,  but  these  were  the  exceptions  and  not  the  rule.  The 
fact  that  so  large  a  number  of  most  competent  medical  men'left  their 
remunerative  practice  to  devote  their  time  and  energy  to  the  service 
of  their  country,  Avith  most  inadequate  compensation,  must  always  be 
accounted  to  the  credit  of  our  profession.  In  extenuation  of  the  fact 
that  medical  ofiicers  failed  to  recognize  many  cases  of  typhoid  fever, 
it  must  be  said  that  the  regimental  medical  officer  had  the  majority 
of  these  cases  under  observation  for  so  short  a  time  that  with  thf^ 
means  at  his  command  it  was  quite  impossible  in  a  large  percentage 
of  the  cases  to  make  a  positive  diagnosis.  The  rules  required  that  all 
cases  of  sickness  of  forty-eight  hours'  duration  should  be  sent  to  the 
division  hospital.  This  rule  is  a  wise  one,  and  it  is  unfortunate  that 
it  was  not  always  obeyed.  It  is  undoubtedly  true  that  typhoid  fever 
was  often  spread  through  a  regiment  by  keeping  cases  of  this  disease 
in  quarters  or  in  regimental  hospitals,  where  provision  for  the  disin- 
fection of  stools  and  the  care  of  patients  were  wholly  inadequate,  to 
say  nothing  of  the  fact  that  the  time  of  the  regimental  medical  officer 
was  so  occupied  with  matters  pertaining  to  camp  sanitation  and  with 
the  care  of  numerous  cases  of  temporary,  illness  that  he  was  not  able 
to  give  sufficient  attention  to  those  sick  with  typhoid  fever.  More- 
over, regimental  medical  officers  were  frequently  detached  from  their 
commands  and  placed  on  duty  in  division  hospitals  or  elsewhere. 

It  will  be  seen  from  figures  to  be  given  later,  in  which  we  compare 
the  mortality  from  typhoid  fever  in  the  Army  with  that  from  the 
same  disease  in  civil  jDractice,  that  the  a,rmj  surgeon  in  his  failure  to 
recognize  all  cases  of  typhoid  fever  showed  no  greater  incapacitj^  than 
that  which  is  daily  shown  by  physicians  in  many  of  the  larger  cities 
in  our  country. 

In  our  list  of  ' '  probable  "  cases  of  typhoid  fever  it  is  to  be  presumed 
that  we  have  included  a  few  which  were  not  actually  cases  of  this 
disease.  However,  we  think  that  the  death  rate  among  the  cases  of 
probable  typhoid  fever  shows  that  we  have  not  overestimated  the 
number.  Be  this  as  it  may,  we  have  endeavored  to  give  every  fact 
that  we  could  obtain  concerning  each  case.  We  have  endeavored  to 
make  this  report  a  full  and  complete  statement  of  facts,  from  which 
we  have  drawn  certain  conclusions.  The  facts  are  placed  before  the 
reader;  these  he  must  accept.  With  our  conclusions  he  may  agree 
or  he  may  draw  others  to  suit  himself.  In  endeavoring  to  state  all 
the  facts,  we  have  made  this  report  somewhat  voluminous,  but  we 
think  we  have  been  justified  in  doing  this.  Our  sole  endeavor  has 
been  to  get  as  near  the  absolute  truth  as  possible. 


CHAPTER  I. 

TYPHOID  FEVER  IN  THE  FIRST  DIVISION,  FIRST  ARMY  CORPS. 

Commands. — First  Kentucky,  Third  Wisconsin,  Fifth  Illi- 
nois, Fourth  Ohio,  Third  Illinois,  Fourth  Pennsylvania,  Six- 
teenth Pennsylvania,  Second  Wisconsin,  and  Third  Kentucky. 

GENERAL   REMARKS. 

It  is  quite  certain  that  most,  if  not  all,  of  the  regiments  of  this 
division  reached  Chickamauga  with  one  or  more  men  infected  vnth 
typhoid  fever.  The  number  of  cases  of  probable  typhoid  fever  devel- 
oped in  this  division,  with  a  mean  strength  of  11,339  officers  and  men 
.it  Chickamauga  Park,  may  be  tabulated  as  follows: 


Commands. 


Arrived . 


Left. 


Number 
of  cases. 


1st  Kentucky  . 
3d  Wisconsin . 
5th  Illinois 


4tliOhio 

3d   Illinois 

4th  Pennsylvania. 


16th  Pennsylvania . 

2d    Wisconsin 

3d   Kentucky 


First  Brigade. 


June  11  I  July  26 
May  15  July  5 
May  17     Aug.  13 


Second  Brigade. 


Third  Brigade. 


May  16 
May  17 
May  16 


May  17 

..  do 

June  2 


July  22 
...do.... 
July  23 


July    6 
—do.... 

July  28 


19 

60 
26 


It  may  possibly  be  of  interest  to  endeavor  to  ascertain  whether  or 
not  the  rapidity  with  which  typhoid  fever  spread  among  the  different 
regiments  was  in  direct  proportion  to  the  number  of  infected  men  in 
the  regiment  when  it  reached  Chickamauga.  We  do  not  suppose  that 
this  question  can  be  answered  conclusively  and  positively,  but  the 
inquiry  may  be  of  some  interest.  We  will  compare  the  Third  Illinois 
with  the  other  regiments  of  the  same  brigade.  Practically  the  regi- 
ments of  this  brigade  came  to  the  park  and  left  at  the  same  time. 
During  the  fourteen  daj^s  that  remained  of  May,  after  the  arrival  of 
the  Third  Illinois,  this  regiment  developed  9  cases  of  probable  typhoid 
fever.  We  will  suppose  that  all  of  these  were  infected  before  the 
regiment  reached  Chickamauga.  Then  we  may  say  that  this  regiment 
had  within  itself  9  foci  for  the  distribution  of  the  disease  and  from 
these  foci  there  were  developed,  up  to  July  22,  60  cases  of  probable 

11 


12 

typhoid  fevei-.  During  the  fifteen  days  that  remained  of  the  month 
of  Maj^  after  the  arrival  of  the  Fourth  Ohio,  there  developed  in  this 
regiment  6  cases  of  probable  typhoid  fever,  and  from  these  6  foci  there 
developed,  up  to  July  22,  19  cases  of  probable  typhoid.  During  the 
fifteen  days  that  remained  of  the  month  of  May,  after  the  arrival  of 
the  Fourth  Pennsylvania,  there  were  no  cases  of  typhoid  fever  in  this 
regiment  and  26  cases  developed  by  July  23.  We  have  carried  out 
this  line  of  inquiry  in  several  brigades  and  have  reached  the  general 
conclusion  suggested  by  the  above-given  figures,  i.  e.,  there  is  no  con- 
stant relation  between  the  number  of  men  infected  with  typhoid  fever 
in  a  regiment  at  the  time  of  its  going  into  a  camp  and  the  number 
that  developed  the  disease  outside  of  those  previously  infected  within 
a  given  time.  The  explanation  for  this  is  not  difficult  to  find.  The 
means  for  the  spread  of  the  infection  must  vary  in  every  command. 

There  is  one  point  in  connection  with  the  camp  of  the  Second  Bri- 
gade of  the  First  Division  at  Chickamauga,  which  may  be  worthy  of 
consideration.  From  April  22  to  30, 1898,  the  Sixteenth  U.  S.  Infantry 
was  encamped  in  Chickamauga  Park.  At  this  encampment  at  this 
place  this  regiment  reported  no  sickness,  but  soon  after  it  reached 
Tampa  in  May,  1898,  it  reported  13  cases  of  acute  intestinal  catarrh, 
3  cases  of  diarrhea,  and  3  cases  of  typhoid  fever.  When  the  Second 
Brigade  of  the  First  Division  of  the  First  Armj^  Corps  was  located  in 
Chickamauga  Park,  the  regimental  camp  of  the  Third  Illinois  occupied 
a  part  of  the  site  recently  vacated  by  the  Sixteenth  U.  S.  Infantry, 
while  the  other  regiments  of  this  brigade  were  placed  some  distance 
away.  It  is  possible  that  the  Sixteenth  IT.  S.  Infantry  might  have 
infected  the  ground  subsequently  occupied  by  the  Third  Illinois.  As 
an  isolated  instance,  this  fact  can  have  no  great  significance;  but  we 
have  found  numerous  similar  instances,  and  we  are  strongly  of  the 
opinion  that  only  in  case  of  the  most  urgent  military  necessity  should 
any  command  be  placed  on  a  site  recently  vacated  by  another. 

It  must  be  evident  from  the  histories  of  the  regiments  of  this  divi- 
sion that  militarj^  organizations  after  becoming  widelj^  infected  with 
typhoid  fever  do  not  lose  this  infection  on  changing  locality  of  camp, 
even  when  all  the  sick  are  left  behind  and  the  site  to  which  the  com- 
mand removes  is  free  from  infection.  The  infection  is  carried  in  the 
bodies  of  the  men,  in  their  clothing,  bedding,  and  tentage.  Thorough 
disinfection  of  everything  in  addition  to  change  of  location  is  neces- 
sary in  order  to  stamp  out  typhoid  fever  after  it  has  become  widel}^ 
distributed  in  a  command. 

We  have  not  been  able  to  obtain  the  records  of  the  hospital  of  this 
division. 


13 


Summary 

Of 

deatlis  in  the  First  Division 

Of 

the  Fii 

'St  A7 

my  Corps 

Commands. 

Total 
deaths. 

Deaths 

due  to 

typhoid 

fever. 

1st  Kentucky     

First  Brigade. 

28 
36 
16 

18 

3d  Wisconsin 

21 

8 

Total 

80 

50 

Second  Brigade. 

4th  Ohio 

26 
44 
35 

19 

Sdniinois            

^ 

24 

Total 

105 

68 

Til  ird  Brigade. 

16th  Pennsylvania 

40 
41 
17 

34 

27 

3d  Kentucky , 

11 

Total 

98 

73 

Total  deaths 283 

Deaths  due  to  typhoid  fever .. 190 

Percentage  of  deaths  from  typhoid  to  total  deaths - 67. 49 


CHAPTER  II. 


TYPHOID  FEVER  IN  THE  SECOND  DIVISION  OF  THE  FIRST 

ARMY  CORPS. 

Cominands. — Thirty-first  Michigan.  One  hundred  and  sixti- 
eth Indiana,  First  Georgia,  One  hundred  and  fifty-eighth 
Indiana,  Sixth  Ohio,  First  West  Virginia,  First  Pennsylvania, 
Fourteenth  Minnesota,  and  Second  Ohio. 

GENERAL   REMAKKS. 

It  seems  to  us  more  than  probable  that  the  water  supply  for  this 
division  during  May,  June,  and  July  at  Chickamauga  became  infected 
with  the  specific  poison  of  typhoid  fever.  We  think  that  this  was 
most  probably  true  of  the  Jay's  Mill  well,  from  which  the  First  and 
Second  brigades  obtained  their  water  supply  in  part,  and  of  the 
Brotherton  Road  well,  from  which  the  Third  Brigade  obtained  its 
water  supplj'  for  some  time  after  its  arrival.  The  location  of  both  of 
these  wells  with  reference  to  the  camps  which  thej'  supplied,  together 
with  the  fact  that  these  camps  were  infected,  renders  it  much  more 
than  probable  that  the  water  of  these  wells  became  infected  with 
typhoid  fever.  We  are  quite  positive  in  our  belief  that  water  infec- 
tion was  one  of  the  means  by  which  typhoid  fever  was  spread  through 
this  division  while  at  Chickamauga.  It  is  unfortunate  that  proper 
bacteriological  studies  of  these  waters  could  not  have  been  made  at 
the  time.  As  has  already  been  stated,  we  see  no  reason  for  believing 
that  these  wells  were  infected  when  the  troops  arrived.  In  fact,  we 
have  already  given  strong  reasons  for  believing  that  these  wells  were 


14 

not  infected  at  that  time.  Employees  about  the  park  had  long  been 
accustomed  to  drink  these  waters,  and  typhoid  fever  had  not  followed. 
The  water  from  these  wells  did  not  introduce  typhoid  fever  among 
the  troops.  The  troops  brought  the  disease,  infected  the  water,  and 
then  drank  it.  We  do  not  make  these  statements  as  demonstrated 
facts,  but  as  the  opinions  which  we  have  reached  as  a  result  of  our 
study. 

However,  water  was  not  the  only  means  by  which  typhoid  fever  was 
spread  among  the  troops  of  this  division  at  Chickamauga.  Like  all 
other  organizations  in  the  park  at  that  time,  the  camps  of  the  regi- 
ments of  this  division  became  terribly  polluted.  Sinks  could  not  be 
properly  constructed.  Their  contents  were  not  kept  covered  or  even 
kept  within  bounds,  but  overflowed  and  polluted  the  soil  about  them. 
Flies  swarmed  alternately  about  the  sinks  and  the  mess  tents.  Men 
carried  infected  filth  on  their  persons  and  in  their  clothing.  Tents, 
blankets,  and  equipage  in  general  became  infected,  and  when  this 
division  moved  to  Knoxville  it  carried  with  it  innumerable  cultures 
of  the  typhoid  bacillus. 

At  Knoxville  the  water  supply  was  not  contaminated,  but  the  infec- 
tion brought  in  the  bodies  of  the  men  and  in  their  clothing  and  equip- 
age was  disseminated  by  flies  and  the  epidemic  continued  until  the 
coming  of  cool  weather  destroyed  these  pests  which  had  inflicted 
greater  loss  upon  the  American  soldiers  than  the  arms  of  Spain. 

The  fact  that  the  epidemic  of  typhoid  fever  at  Knoxville  disap- 
peared with  the  approach  of  cool  weather — at  a  time  when  tj^Dhoid 
fever  is  generally  found  to  be  most  rife  in  civil  practice — is  to  us  a 
strong  confirmation  of  our  belief  that  flies  had  much  to  do  "with  the 
dissemination  of  this  infection. 

Summary  of  deaths  in  the  Second  Division  of  the  First  Army  Corps, 


Commands. 


j  Deatlis 
Total    [   due  to 
deatlis.  i  typhoid 
I    fever. 


31st  Michigan - 

160th  Indiana  . . 

1st  Georgia  .. 


158th  Indiana 

6th  Ohio 

Ist  West  Virginia  , 


1st  Pennsylvania . 

14th  Minnesota 

2d  Ohio 


First  Brigade. 


Second  Brigade. 


Third  Brigade. 


27 
11 

10 

16 
8 
9 

48 

33 

13 
21 
15 

10 
19 
13 

48 

41 

14 
11 
14 

12 
10 
13 

39 


35 


Total  deatns --- 135 

Deaths  due  to  tj^lioid  fever .-- 109 

Percentage  of  deaths  from  tjrphoid  to  total  deaths 80.  7 


15 
CHAPTER  III. 

TYPHOID  FEVER  IN  THE  THIRD  DIVISION  OF  THE  FIRST  ARMY 

CORPS. 

Commands.— Fifth  Pennsylvania,  Twelfth  Minnesota,  First 
South  Carolina,  Eighth  Massachusetts,  Twenty-first  Kansas, 
Twelfth  New  York,  Second  Missouri,  First  New  Hampshire, 
and  Ninth  Pennsylvania. 

GENERAL   REMARKS. 

All  the  regiments  of  this  division  excepting  the  First  South  Caro 
lina  arrived  at  Ghickamanga  Park,  Ga. ,  practically  at  the  same  time 
(May  20);  all  left  abont  the  same  time  (August  23-27),  and  all  went 
to  Lexington,  Ky.  The  following  table  gives  figures  showing  some  of 
the  most  important  facts  concerning  typhoid  fever  in  the  different 
regiments  of  this  division : 


Commands. 

Date  of 
first 
case. 

Total 
number 
of  cases. 

Number 
of  recog- 
nized 
cases. 

Total 
deaths. 

Deaths 

from 

typhoid. 

Per  cent 

of  deaths 

among 

probable 

cases. 

Per  cent 
of  deaths 

among 

recognized 

cases. 

First  Brigade. 

5th  Pennsylvania 

12th  Minnesota 

May  19 
May  30 

May  28 
May  21 
June   6 

338 
433 

273 
394 
490 

268 
297 
334 

152 

144 

157 

95 

144 

181 
313 
155 

16 

20 

30 
33 
31 

30 
33 

28 

16 
19 

19 
31 
30 

19 
30 
26 

4.73 
4.38 

7.00 
7.14 

4.00 

7.08 
10.00 

7.78 

10.53 
13.13 

Second  Brigade. 
8th  Massachusetts 

12.10 
33.10 

13th  New  York          ,    . 

13.88 

Third  Brigade. 

May  26 

10.49 

1st  New  Hampshire  — 
9th  Pennsylvania 

May  24 
May  31 

14.13 
16.77 

Total  number  of  cases  of  probable  typhoid  fever  in  the  eight  regiments.  -  2, 736 

Total  number  of  cases  of  recognized  typhoid  fever  in  the  eight  regiments.  1, 241 

Total  number  of  deaths  in  the  eight  regiments ... 189 

Total  number  of  deaths  from  typhoid  fever  in  the  eight  regiments 170 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever 6. 23 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever 13. 69 

The  mean  strength  of  these  eight  regiments  from  May  to  September,  as 

nearly  as  we  can  ascertain,  was.  -   . 10, 329 

Figuring  on  this  basis  we  find  the  percentage  of  probable  typhoid  fever  in 

these  eight  regiments  to  be 26. 39 

It  was  quite  generally  believed  among  medical  officers  at  Chicka- 
mauga  that  the  Second  Division  of  this  corps  developed  typhoid  fever 
much  later  than  the  Third  Division.  As  we  have  already  learned, 
the  Second  Division  obtained  its  water  supply  from  wells  and  springs; 
the  Third  Division  obtained  its  water  supply  principally  from  the 
pipes  that  distributed  the  water  of  Chickamauga  Creek.     Many  army 


16 

medical  officers  believed  that  the  Chickamauga  Creek  water  became 
contaminated  early  in  July,  and  that  regiments  supplied  with  that 
water  developed  tj^phoid  fever  much  more  prominently  and  rapidly 
than  the  other  regiments  did.  In  order  to  determine  how  much  of 
truth  there  may  have  been  in  this  general  idea,  we  will  tabulate  the 
principal  figures  concerning  typhoid  fever  in  both  of  these  divisions. 
In  doing  so  we  will  omit  the  One  hundred  and  sixtieth  Indiana  from 
the  Second  Division  and  the  First  South  Carolina  from  the  Third 
Division.  This  will  make  the  mean  strength  of  the  two  divisions 
practically  the  same.  We  omit  these  two  regiments  because  both  of 
them  left  Chickamauga  much  earlier  than  the  other  regiments. 
Omitting  these  two,  all  the  regiments  of  the  Second  and  Third  Divi- 
sions reached  Chickamauga  within  a  few  days  (May  17-22),  and  all 
left  within  a  few  days  (August  21-29)  with  the  exception  of  the  fact 
that  the  First  Georgia  did  not  reach  Chickamauga  until  June  17. 
However,  this  regiment  had  been  encamped  at  Griffin,  Ga. ,  and  we 
will  include  the  cases  of  typhoid  fever  developed  in  this  regiment  at 
that  place. 


Commands. 


SECOND  DIVISION. 

First  Brigade. 


31st  MicMgan 
1st  Georgia .  - 


Date  of 
first 
case. 


June  1 
June  6 


Number  ' 
of  cases    !    Total 
developed   number 
at  Chick-    of  cases 
amauga 


Second  Brigade. 


158th  Indiana 
6th  Ohio 


June   6 

May  18 

ist  West  Virginia - j  June  6 

Third  Brigade. 

1st  Pennsylvania.. May  13 

14th  Minnesota --    May  27 

2d    Ohio May  20 


Total - 


THIRD   DIVISION. 

First  Brigade. 


5th  Pennsylvania - 
13th  Minnesota 


Second  Brigade. 


8th  Massachusetts - 

21st  Kansas. 

12th  New  York 


Third  Brigade. 

2d   Missouri 

1st  New  Hampshire 

9th  Pennsylvania 


Total. 


May  19 

May  20 


May  28 
May  21 
June   6 


May  26 
May  34 
May  31 


95 


129 
114 
160 


834 


182 
320 


55 
153 
197 


149 
261 

287 

1,604 


239 
130 


128 
391 
260 


232 

286 
403 


1,949 


338 
433 


272 
294 
490 


368 
397 
334 


10 


124 


Deaths 

from 

typhoid. 


190 


101 


19 
30 
26 

170 


17 

Total  number  of  cases  of  probable  typhoid  fever  in  eight  regiments  of 
the  Second  Division __. 1,949 

Total  number  of  cases  of  probable  typhoid  fever  in  eight  regiments  of 
the  Third  Division . .  _ . . .  ; 2, 736 

Excess  of  cases  of  probable  typhoid  fever  in  the  Third  Division 

over  those  in  the  Second  Division . 777 

Total  number  of  cases  of  probable  typhoid  fever  developed  in  eight 

regiments  of  the  Second  Division  at  Chickamauga 834 

Total  number  of  cases  of  probable  typhoid  fever  developed  in  eight 
regiments  of  the  Third  Division  at  Chickamauga.  - .  1,  604 


Excess  of  cases  of  probable  typhoid  fever  developed  at  Chicka- 
mauga in  the  Third  Division  over  those  developed  in  the  Second 
Division . ... .   _. 770 

Total  number  of  deaths  in  eight  regiments  of  the  Second  Division 134 

Total  number  of  deaths  in  eight  regiments  of  the  Third  Division 190 


Excess  of  deaths  in  the  Third  Division  over  those  in  the  Second 

Division    . . .     .         ^     _       66 

Total  number  of  deaths  from  typhoid  fever  in  eight  regiments  of  the 

Second  Division .  _  -  . . ... .  _       101 

Total  number  of  deaths  from  typhoid  fever  in  eight  regiments  of  the 
Third  Division 170 


Excess  of  deaths  from  typhoid  fever  in  the  Third  Division  over 

those  in  the  Second  Division , . 69 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  in  the  Second 

Division . . .    . .  5. 17 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  in  the  Third 
Division '. 6.23 

We  certainly  must  conclude  from  the  above-given  figures  that  the 
general  idea  prevalent  among  medical  officers  at  Chickamauga  that 
typhoid  fever  was  much  more  prevalent  in  the  Third  Division  of  the 
First  Army  Corps  than  in  the  Second  Division  of  the  same  corps  is 
correct.  Typhoid  fever  dilfused  more  rapidly  and  more  widely 
through  the  Third  Division  than  it  did  through  the  Second  Division. 
Whether  or  not  the  greater  prevalence  of  typhoid  fever  in  the  Third 
Division  was  due  to  the  fact  that  the  regiments  of  this  division  used 
Chickamauga  Creek  water  we  will  not  at  present  attempt  to  determine. 
We  will  leave  the  discussion  of  this  subject  until  we  have  studied 
typhoid  fever  in  the  Third  Corps. 
7273 2 


18 


Summary  of  deaths  in  the  Third  Division  of  the  First  Army  Corps. 


Commands. 


Total 
deaths. 


Deaths 

due  to 

typhoid 

fever. 


5th  Pennsylvania . . 

12th  Minnesota 

1st  South  Carolina. 


Total . 


8th  Massachusetts  . 

21st  Kansas  — 

12th  New  York 


Total . 


2d  Missouri 

1st  New  Plampshire  . 
9th  Pennsylvania  — 


Total . 


First  Brigade. 


Second  Brigade. 


Third  Brigade. 


56 

45 

30 

19 

23 

21 

21 

20 

74 

60 

20 

19 

32 

30 

28 

26 

75 


Total  deaths 210 

Deaths  due  to  typhoid  fever __- .-. 180 

Percentage  of  deaths  from  typhoid  to  total  deaths 85. 71 

In  comparing  the  extent  to  which  typhoid  fever  prevailed  in  the 
different  organizations  of  this  corps,  one  question  that  very  naturally 
arises  is:  Did  the  regiments  that  remained  at  Chickamauga  suffer 
more  or  less  from  typhoid  fever  than  those  that  left  Chickamauga 
earlier  in  the  season?  In  order  to  study  this  question  we  will  divide 
the  regiments  of  this  corps  into  two  groups.  The  first  group  will  con- 
tain those  regiments  that  left  Chickamauga  before  August  3,  1898. 
The  second  group  will  contain  those  regiments  which  left  Chicka- 
mauga subsequent  to  August  3,  1898.  We  will  endeavor  to  ascertain 
which  of  these  groups  of  regiments  suffered  more  severely  from 
typhoid'  fever,  and  which  had  the  greater  death  rate.  In  making 
this  comparison  we  will  have  to  depend  upon  the  total  number  of 
deaths  and  the  deaths  attributed  to  typhoid  fever. 

FIRST  GROUP. 


Total 
deaths. 


Deaths 

from 

typhoid. 


Per  cent 

of  deaths 

among 

probable 

cases. 


Per  cent 

of  deaths 

among 

recognized 

cases. 


1st  Kentucky 

3d  Wisconsin 

5th  Illinois 

4th  Ohio 

3d    Illinois 

4th  Pennsylvania . . 
16th  Pennsylvania   . 

3d    Wisconsin 

3d    Kentucky 

160th  Indiana 

1st  South  Carolina 


6.87 
6.34 
6.40 


4.57 


8.20 
.5.02 
3.58 


20.45 
22.41 

7.08 


16.77 


23.89 

'i7.6a 


19 


SECOND  GROUP. 


31st 

1st 

158th 

lith 

1st 

1st 

11th 
;.'cl 
.5th 

12th 
8th 

21st 

12th 
2d 
1st 
9th 


Michigan 

Georgia. 

Indiana 

Ohio - 

West  Virginia  . . . 

Pennsylvania 

Minnesota 

Ohio...- 

Pennsylvania 

Minnesota 

Massachusetts  - . 

Kansas 

New  York 

Missouri 

New  Hampshire . 
Pennsylvania 


Per  cent 

Death 

of  deaths 

from 

among 

typhoid. 

probable 

cases. 

16 

6.69 

-9 

7.50 

10 

7.81 

19 

6.52 

12 

4.61 

13 

5.40 

10 

3.49 

13 

3.22 

16 

4.73 

19 

4.38 

19 

7.00 

21 

7.14 

20 

4.00 

19 

7.08 

30 

10.00 

26 

7.78 

Per  cent 
of  deaths 

among 

recognized 

cases. 

18.60 
35.00 
20.40 
12.83 
11.32 
7.10 
6.85 
6.77 
10.53 
13.19 
13.10 
22.10 
13.88 
10.49 
14.13 
16.77 


Eleven  regiments  in  the  first  group  lost  from  all  causes. 314 

These  1 1  regiments  had  an  aggregate  strength  when  they  lef  t  Chickamauga  of  _  13, 814 
Percentage  of  deaths  from  all  causes  in  the  11  regiments  that  left  Chicka- 
mauga early .- 2.26 

Sixteen  regiments  in  the  second  group  lost  from  all  causes 814 

These  1 6  regiments  had  an  aggregate  strength  when  they  left  Chickamauga  of  _  20, 334 
Percentage  of  deaths  from  all  causes  in  the  16  regiments  of  the  second 
group,  which  left  Chickamauga  later  _ . 1 .  54 

It  will  be  seen  from  these  figures  that  so  far  as  loss  by  death  from 
all  causes  goes,  these  two  groups  differed,  the  loss  being  greater  in 
the  regiments  that  left  Chickamauga  early. 

Eleven  regiments  in  the  first  group  lost  by  death  from  typhoid  fever 208 

Percentage  of  deaths  from  typhoid  fever  in  the  11  regiments  that  left  Chick- 
amauga early . .  . . . .   1.  50 

Sixteen  regiments  in  the  second  group  lost  by  death  from  typhoid  fever 271 

Percentage  of  deaths  from  typhoid  fever  in  the  1 6  regiments  that  remained 
longer  at  Chickamauga ..   ..    1,33 

It  will  be  seen  from  these  figures  that  while  there  is  a  marked  dif- 
ference in  the  percentage  of  total  deaths  in  these  two  groups,  the 
percentages  of  deaths  from  typhoid  fever  differ  less. 
Seven  regiments  out  of  the  first  group  had  among  the  probable  cases  of 

typhoid  fever  an  average  death  rate  of per  cent.  ^  4. 39 

Sixteen  regiments  in  the  second  group  had  among  the  probable  cases  of 

typhoid  fever  an  average  death  rate  of per  cent, .  6. 03 

These  figures,  in  our  opinion,  furnish  additional  evidence  to  our  claim 
that  we  have  not  overestimated  the  number  of  cases  of  typhoid  fever. 

"We  will  next  inquire  whether  or  not  the  regiments  that  went  to 
Porto  Rico  suffered  more  severely  by  deaths  from  all  causes  than  did 
the  regiments  that  remained  in  this  country.     The  following  figures 
bear  upon  this  inquiry: 
Seven  regiments  of  this  corps  that  went  to  Porto  Rico  had  a  total  loss  by 

death  of . .     . .         .    .    250 

Aggregate  strength  of  these  regiments  on  leaving  Chickamauga. 8, 750 

Percentage  of  deaths  from  all  causes  among  the  regiments  that  went  to 

Porto  Rico 2.85 

Percentage  of  deaths  from  all  causes  among  those  regiments  that  remained 

at  Chickamauga .  - 1. 51 


20 


It  will  be  seen  from  these  figures  that  the  loss  of  life  was  materially 
increased  by  sending  these  troops  to  Porto  Rico. 

The  following  table  gives  figures  showing  the  most  important  facts 
concerning  typhoid  fever  in  the  First  Army  Corps : 

Note.— The  regiments  marked  *  went  to  Porto  Rico.    For  these  regiments  the  "Total  deaths  " 
and  "  Deaths  from  typhoid  "  are  those  which  occurred  at  Chickamauga. 


Date  of 
first  case. 

Total 
number 
of  cases. 

Number 
of  rec- 
ognized 
cases. 

Total 
deaths. 

Deaths 

from 

typhoid. 

Per  cent 
of  deaths 

among 
probable 

cases. 

Per  cent 
of  deaths 

among 

recognized 

cases. 

FIRST  DIVISION. 

First  Brigade. 

*lst  Kentucky 

June  19 
May  24 
May  16 

363 
378 
125 

86 
107 
113 

13 
14 
16 

6 
9 
8 

2.29 
2.38 
6.40 

6.81 

3d   Wisconsin     .    . . 

8.41 

5th  Illinois 

7.08 

Second  Brigade. 

'*4thOhio 

May  17 

11 
34 
31 

7 
11 
14 

*3d   Illinois 

546 

149 

3.01 

7.38 

*  4th  Pennsylvania 

June   1 

Third  Brigade. 

*  16th  Pennsylvania 

3d    Wisconsin 

May    8 
May  11 

15 

32 
17 

13 
33 
11 

329 
319 

113 

7 
5.02 

20.3 

SECOND  DIVISION. 

First  Brigade. 

31st  Michigan 

160th  Indiana 

1st  Georgia 

June  1 
July    4 
June   6 

239 
333 
120 

86 
47 
36 

37 
11 
10 

16 
8 
9 

6.69 
3.58 
7.50 

18.60 
17.03 
35 

Second  Brigade. 

158th  Indiana 

6th  Ohio    .      .            .    . 

June   6 
May  18 
June   6 

138 
291 
360 

49 
148 
106 

13 
21 
15 

10 
19 
13 

7.81 
6.52 
4.61 

20.40 
13.83 

1st  West  Virginia 

11.31 

Third  Brigade. 

1st  Pennsylvania 

lith  Minnesota 

May  12 
May  27 
May  20 

333 
386 
403 

169 
146 
192 

14 
11 
14 

13 
10 
13 

5.40 
3.49 
3.22 

7.10 
6.85 

2d  Ohio 

6.77 

THIRD   DIVISION. 

First  Brigade. 

5th  Pennsylvania    

May  19 
May  20 

338 
433 

152 
144 

16 
20 
20 

16 
19 
10 

4.73 
4.38 

10.53 
13.19 

1st  South  Carolina   . 

Second  Brigade. 

8th  Massachusetts 

21at  Kansas 

I3th  New  York 

May  38 
May  31 
June   6 

373 
394 
490 

157 
95 
144 

30 
23 
31 

19 

21 
20 

7.14 

4 

13.10 
22.10 
13.88 

Tliird  Brigade. 

2d   Missouri 

1st  New  Hampshire 

9th  Pennsylvania 

May  36 
May  34 
May  31 

268 
297 
334 

181 
213 
155 

30 
32 
38 

19 
30 
26 

7.08 
10 
7.78 

10.49 
14.13 
16.77 

Total  niimber  of  cases  of  probable  typhoid  fever  in  this  corps,  excluding  the 

7  regiments  that  went  to  Porto  Rico  and  the  First  South  Carolina    5, 242 

Aggregate  strength  of  these  19  regiments _ . 24, 235 

Percentage  of  typhoid  fever  among  these  19  regiments 21. 62 

Total  number  of  deaths  from  typhoid  fever  in  these  19  regiments .  -        298 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever 5. 08 


21 

Tliis  percentage  is  too  low  Tor  two  reasons:  First,  it  is  certain  that 
we  have  not  l)een  abh'  to  obtain  a  complete  list  of  deaths;  second,  in 
the  list  of  deaths  as  we  have  given  it  several  cases  attributed  to  other 
canses  were  undoubtedly  due  to  typhoid  fever. 

In  these  19  regiments  the  number  of  recognized  cases  of  typhoid  fever  was.     3, 552 
Percentage  of  deaths  among  recognized  cases  of  typhoid  fever.  _ _     11. 67 

Of  course  this  last  statement  can  not  be  correct,  because  all  the 
deaths  from  typhoid  fever  did  not  occur  among  the  recognized  cases. 
From  these  figures  we  have  no  hesitancy  in  concluding  that  our  list 
of  probable  typhoid  fevers  more  nearly  represents  the  actual  number 
than  does  the  list  of  recognized  cases. 

Summary  of  deaths  in  the  First  Army  Corps. 


Commands. 


Total 
deaths. 


Deaths 

due  to 

typhoid 

fever. 


Percent- 
age of 
deaths 
from  ty- 
phoid to 

total 
deaths. 


First  Division  . . 
Second  Division 
Third  Division  . 

Total 


283 
135 
310 


190 
109 
180 


479 


80.74 
85.71 


76.27 


In  this  tabular  statement  of  the  First  Army  Corps  are  included 
seven  regiments  of  the  First  Division,  which  started  early  for  Porto 
Rico,  and  the  First  South  Carolina  Regiment  (Third  Division).  The 
records  of  these  eight  regiments  are  very  incomplete,  and  they  have 
therefore  been  omitted  from  the  following  general  summary  of  the 
statistics  of  the  board: 

Table  shoiving  for  certain  regiments  of  the  First  Army  Corps  assemhled  at  Chicka- 
mauga  the  Tnortality  and  morbidity  frovo  typhoid  fever. 


Regiments. 


Mean 
strength. 


Cases  of  typhoid  fever. 


Certain. 


Certain 

and 
probable. 


Deaths 
from 

typhoid 
fever. 


Deaths 
from  all 
diseases. 


FIRST  DIVISION. 

5th  Illinois 

3d    Kentucky 

Total  

SECOND  DIVISION 

31st  Michigan 

160th  Indiana 

1st  Georgia 

158th  Indiana 

6th  Ohio 

1st  West  Virginia 

1st  Pennsylvania 

14th  Minnesota 

2d    Ohio 

Total  


1,296 
1,393 


3,  .589 


1,290 
1,313 
1,212 

1,288 
1,399 
1,298 
1,071 
1,377 
1,297 


11,344 


113 
219 


125 
219 


333 


344 


148 
106 


146 
192 


239 
323 
120 
128 
291 
260 
333 
286 
403 


979 


2,172 


19 


16 


109 


33 


27 
11 
10 
12 
21 
15 
14 
11 
14 


135 


22 

Table  sJunmny  for  certain  regiments  of  the  First  Arviy  Corps,  etc. — Continued. 


Mean 
strength. 

Cases  of  typhoid  fever. 

Deaths 

Deaths 
from  all 
diseases. 

Regiments. 

Certain. 

Certain 

and 
probable. 

from 

typhoid 

fever. 

THIRD  DIVISION. 

1,291 
1,299 
1,317 
1,264 
1,302 
1,269 
1.269 
1,291 

153 
144 
157 
95 
144 

338 
433 

272 
294 
490 

16 
19 
19 
21 
20 
19 
30 
26 

16 

12th  Minnesota       -          .    

20 

30 

23 

12th  New  York        .             

21 

181  :              268 
213  i               397 

20 

32 

155 

334 

28 

Total                 .... 

10,302 

1,241 

3,726 

170 

190 

CAVALRY  BRIGADE. 

3d   U.  S.  Volunteers         

1,013 

1,299 
833 

103 
68 
189 

270 
220 
189 

13 
16 

7 

15 

17 

7 

Total 

3,145 

360 

679 

36 

39 

Total,  First  Army  Corps 

37,380 

2,913 

5,931 

334 

397 

Deaths  from  ty- 
phoid fever  in 
100  cases  of— 

Percent- 
age of 
deaths 
from  ty- 
phoid to 
all  dis- 
eases. 

Morbidity  of  ty- 
phoid  fever 
in  1,000  mean 
strength— 

Deaths 
from  ty- 
phoid 
fever  in 
1,000  of 
mean 
strength. 

Regiments. 

Certain 
typhoid. 

Certain 
and 

proba- 
ble. 

For  cer- 
tain 
cases  of 
typhoid. 

"For  cer- 
tain and 
proba- 
ble cases 
of  ty- 
phoid. 

FIRST   DIVISION. 

7.07 
5.03 

6.04 
5.02 

50.00 
64.70 

87.19 
170.69 

96.45 
170. 69 

6.17 

8.50 

Total 

5.72 

5.53 

57.57 

128.83 

132. 86 

7.33 

SECOND  DIVISION. 

31st  Michigan 

18.60 

17.02 

25.00 

20.40 

12.83 

11.32 

7.10 

6.84 

6.77 

6.69 
3.58 
7.50 
7.81 
6.52 
4.61 
5.40 
3.49 
3.32 

59.25 

72.72 
90.00 
83.33 
90.47 
80.00 
85.71 
90.90 
92.85 

66.66 
:i5.82 
29.70 
38.  (J4 

113. 93 
81.66 

1.57.  79 

114.  as 

148.03 

185.27 
169. 96 
99.00 
99.37 
224.01 
.200.30 
207.28 
223.96 
310.  71 

12.40 

6.09 

1st  Georgia           .                .    .  

7.42 

158th  Indiana 

7.76 

14.63 

9.34 

1st  Pennsylvania              

11.20 

7.83 

2d   Ohio                       -      

10.02 

Total 

11.13 

5.01 

80.74 

86.30 

191.46 

9  60 

THIRD   DIVISION. 

10.52 
13.12 
12.10 
23.10 

13.88 
10.49 
14.08 
16.77 

4.73 
4.38 
6.98 
7.14 
4.08 
7.08 
10.10 
7.78 

100.00 
9.5.00 
63. 33 
91.30 
95.23 
95.00 
93.75 
93.85 

117. 73 
110. 85 
119.21 
75. 15 
110.  .59 
142.63 
167. 84 
120.06 

261.81 
333.33 
206.53 
233.  .59 
376.34 
311. 18 
234.04 
258. 71 

12.39 

14.64 

14.42 

16.81 

12th  New  York                                     

1.5.36 

3d    Missouri                . 

14.97 

2.3.64 

9th  Pennsylvania    ..     

20.13 

Total                                         .     .. 

13.69 

6.23 

89.47 

120.46 

264.60 

16.50 

CAVALRY  BRIGADE. 

3d   U.  S.  Volunteers 

13.62 

23.52 

3.70 

4.81 
7.27 
3.70 

86.66 
94.11 
100.00 

101. 67 

52.34 

226.88 

266.53 
169.36 

226.88 

12.83 

1st  Illinois      .      ..  

13.31 

Ist  Ohio  Volunteers 

8.40 

Total 

10.00 

5.30 

92.30 

114.46 

315. 89 

11.44 

Total,  First  Army  Corps 

11.46 

5.64 

84.13 

106.35 

316.35 

12.19 

23 

CHAPTER  IV. 

TYPHOID  FEVER  IN  THE  FIRST  DIVISION.  THIRD  ARMY  CORPS. 

Commands. — Fourteenth  New  York,  First  Missouri,  Fifth 
Maryland.  Second  Nebraska,  Second  New  York,  First  District 
of  Columbia  (no  data),  Third  Tennessee,  First  Vermont,  and 
Eighth  New  York. 

GENERAL  REMARKS. 

Our  knowledge  concerning  the  conditions  existing  among  the  regi- 
ments of  this  division  at  Chickamauga  is  meager  and  fragmentary. 
When  we  reached  Chickamauga  on  our  tour  of  inspection  all  the  regi- 
ments of  this  division  had  departed.  We  obtained  the  testimony  of 
Maj.  Guy  L.  Edie,  who  for  some  time  acted  as  sanitaiy  inspector  for 
this  division.  To  this  testimony  we  are  indebted  for  the  following 
information.  Major  Edie  reached  Chickamauga  August  3,  1898,  and 
began  immediately  to  inspect  these  regiments.  When  asked  as  to 
the  condition  found  in  this  inspection,  he  made  the  foUo^dng  state- 
ment : 

I  found  that  nearly  all  the  companies  had  kitchen  sinks  within  a  few  feet  of  the 
kitchens.  These  sinks  consisted  of  shallow  pits  which  when  filled  were  covered 
with  earth.  Into  these,  kitchen  refuse  and  slops  were  thrown.  The  privy  vaults 
were  dug  to  the  rear,  some  of  them  at  the  proper  distance  but  very  shallow  and 
wide,  and  the  contents  were  imperfectly  covered.  Some  of  these  pits  were  not 
more  than  2  feet  deep.  Neither  earth  nor  lime  had  been  thrown  upon  the  contents. 
They  were  in  a  very_  filthy  condition  and  contained  myriads  of  flies.  I  found  the 
camp  of  the  Third  U.  S.  Cavalry  very  bad.  I  went  through  the  companies  and 
told  the  captains  that  they  would  probably  have  a  great  deal  of  sickness.  I 
rode  through  the  woods  ad.ioining  this  camp  and  saw  at  that  time  14  men  defe- 
cating in  the  woods.  There  were  probably  more,  for  there  was  a  long  stretch  of 
the  woods.  With  the  exception  of  two  regiments  the  locations  of  all  the  organi- 
zations of  this  division  were  pretty,  but  the  sinks  were  in  a  miserable  condition. 
Most  of  these  regiments  had  remained  in  the  same  location  since  coming  to  this 
place.  Efforts  had  been  made,  as  I  found  out  afterwards,  to  change  the  sites  of 
the  camps.  I  advised  that  tlie  regiments  be  moved  out  of  the  woods  into  the 
sunlit  fields,  but  was  told  that  a  man  had  a  lease  of  these  fields  and  that  time 
would  be  necessary  in  order  to  get  a  permit  to  occupy  them.  Later,  lime  was 
obtained,  and  I  instructed  each  regimental  and  brigade  surgeon  to  see  that  each 
regiment  had  a  barrel  of  lime  each  day  and  that  it  be  used  freely  for  both 
kitchen  and  company  sinks.  I  also  advised  that  the  kitchen  refuse  be  hauled 
away  and  that  the  company  sinks  be  dug  deeper  and  the  contents  be  covered  with 
earth  and  lime  each  day.  At  that  time  there  was  not  snfiicient  tentage  for  the 
sick,  and  some  of  them  were  compelled  to  lie  under  files.  A  number  of  the  hos- 
pital tents  did  not  have  floors.  The  quartermaster  was  directed  to  make  requsi- 
sition  for  the  lumber  needed  for  flooring  and  for  hospital  tents.  I  brought  these 
requisitions  over  to  headquarters  and  had  them  approved.  I  then  went  and  saw 
the  quartermaster,  and  very  shortly  afterwards  a  sufficient  quanity  of  hospital 
tents  and  lumber  for  flooring  were  furnished  for  the  division  hospital. 

I  recommended  that  the  men  be  compelled  to  boil  the  water  taken  from  the 
hydrant,  and  an  order  to  this  effect  was  issued.  However,  I  believe  that  this 
order  was  not  fully  obeyed.    Men  frequently  drank  from  the  hydrants,  and  at  two 


24 

reviews  I  saw  men  filling  their  canteens  from  the  hydrants.  This  water  was 
obtained  from  Chickamauga  Creek.  A  number  of  the  regiments,  however,  hauled 
their  water  from  springs  outside  the  park,  principally  from  Blue  Spring  and  Park 
Spring.  There  was  one  driven  well  in  this  division,  and  individually  the  men 
used  water  from  this  well.  This  was  especially  true  of  the  ambulance  corps  and 
of  the  Eighth  New  York  Volunteer  Infantry.  The  water  obtained  from  Blue 
Spring  was  cloudy.  The  water  obtained  from  the  pipes  was  abundant  in  quantity, 
but  of  suspicious  quality.  As  to  obtaining  water  from  the  springs,  there  were 
not  enough  barrels  for  storing  this  water  until  latterly,  when  a  suflicient  supply 
of  barrels  was  obtained. 

Many  huckster  wagons  were  driven  through  the  camps,  and  milk  from  these 
was  generally  sold  to  the  soldiers.  This  milk  was  of  doubtful  quality.  The  milk 
for  the  hospitals  was  sent  from  Blltmore,  N.  C,  and  we  received  about  200  gallons 
of  this  each  day.  This  milk  was  supposed  to  be  good.  An  order  was  issued  to 
keep  venders  of  milk  outside  the  limits  of  the  division. 

The  regimental  and  brigade  officers  were  requested  to  have  the  fruits  and  melons 
offered  for  sale  among  the  men  inspected,  and  to  permit  the  sale  of  only  those  that 
were  apparently  good. 

Wlien  asked  whether  or  not  he  had  formed  any  opinion  concerning 
the  source  arid  the  manner  by  which  typhoid  fever  was  spread  through- 
out this  division,  Major  Edie  made  the  following  statement: 

I  thought  that  the  piped  water  supply  was  infected,  and  there  was  ample  oppor- 
tunity for  the  food  around  the  kitchens  to  get  infected  by  the  flies.  The  fecal 
matter  in  the  pits  was  not  covered,  as  I  have  stated.  The  cook  at  the  division 
hopital  called  my  attention  to  the  fact  that  when  they  were  using  lime  freely 
around  the  sinks  the  flies  alighting  upon  the  food  had  their  feet  covered  with  lime. 
The  great  increase  in  typhoid  fever  was  immediately  after  heavy  rains.  I  should 
say  about  ten  days  or  two  weeks  after  heavy  rains.  We  had.  some  typhoid  fever 
before  that  time,  but  the  great  influx  of  typhoid  cases  came  after  the  heavy  rains. 
There  were  also  numerous  wet- weather  springs  in  the  hollows,  and  many  of  the 
companies  used  this  water.  I  saw  soldiers  drinking  from  these  springs  and  cau- 
tioned them  against  it.  They  thought  that  it  was  good  water,  but  it  was  nothing 
but  a  wet- weather  spring. 

In  regard  to  the  hospital  of  the  First  Division  of  the  Third  Army 
Corps,  Lieut.  Col.  A.  A.  Woodhull,  in  a  report  to  the  Surgeon-General 
un^er  date  of  August  7,  1898,  makes  the  following  statement: 

At  the  time  of  my  inspection,  July  27,  the  hospital  control  was  just  being 
assumed  by  a  newly  arrived  officer,  who  could  not  be  regarded  as  responsible  for 
its  defects  nor  be  credited  with  its  advantages.  The  staff  consists  of  5  medical 
officers,  and  the  enlisted  force  was  95  noncommissioned  officers  and  privates  of 
the  Hospital  Corps.  The  hospital  consists  of  .30  hospital  tents  for  all  purposes, 
containing  at  this  date  179  patients.  The  tents  are  too  crowded,  containing  8 
patients  apiece,  and  they  have  had  10.  There  is  insufficient  space  between  the 
wards,  the  grounds  are  not  adequately  ditched,  and  the  approach  to  the  patients' 
sinks  is  very  poor.  The  sinks  themselves  are  very  bad.  The  hospital  is  not 
divided  into  brigades.  The  Red  Cross  supplies  about  one-half  of  the  clothing 
and  the  bedding.  The  floors  that  have  been  supplied  the  tents  were  furnished  by 
regimental  means.  The  hospital  fund  started  with  $50,  and  there  was  $48  at  the 
end  of  the  month,  but  considerable  expenditures  had  been  made  by  emergency 
funds  supplied  by  the  regiments.  Very  serious  complaints  are  made  as  to  the 
inadequacy  of  the  medical  supplies.  No  atropine  is  on  hand,  and  the  saiol  has 
been  bought  by  private  means.  The  chloroform  supplied  from  the  1st  to  10th  of 
June  was  regarded  as  inert,  although  this  might  depend  on  the  inexperience  of 


25 

the  administrator  in  open-air  work,  but  the  bottles  contained  a  small  part  of  the 
marked  contents.  Chocolate-coated  quinine  tablets  in  stock,  Parke,  Davis  &  Co., 
tablet  125  (563360  in  red),  are  insoluble  and  found  in  the  stools.  I  am  informed 
in  Washington  that  this  is  not  supplied  by  the  Medical  Department.  It  was  evi- 
dently regarded  there  as  part  of  the  regular  supplies.  The  food  as  a  whole  is 
good,  and  the  special  diet  kitchen  was  very  neat  and  appeared  excellent.  Two  of 
a  case  of  twelve  sides  of  bacon  then  on  hand  were  bad.  and  I  personally  observed 
the  maggots  in  them.  There  was  only  one  very  small  coffee  mill,  apparently 
belonging  to  a  mess  chest,  for  the  whole  hospital,  and  one  man  was  employed  all 
day  in  grinding  coffee.  The  average  duration  of  treatment,  excluding  the  typhoid 
cases,  is  stated  at  three  or  four  days.  Cases  are  transferred  to  Leiter  and  to 
McPherson  general  hospitals.  Fifty  men  are  employed  as  nurses  and  are  on  duty 
from  twelve  to  eighteen  hours  continuously,  day  by  day.  As  far  as  observed,  all 
the  hospital  cases  of  this  division  were  taken  into  the  hospital. 

In  looking  over  the  list  of  cases  of  probable  typhoid  fever  in  this 
division  one  is  at  once  struck  by  the  much  greater  number  of  cases  in 
the  Eighth  New  York  than  in  any  other  regiment  of  the  division. 
Since  all  of  these  regiments  used  the  Chickamauga  Creek,  we  must 
conclude  that  the  great  prevalence  of  typhoid  fever  in  the  Eighth  New 
York  must  have  been  due  to  some  special  local  condition  and  that 
water  infection  could  not  have  been  the  most  important  factor  in  the 
spread  of  typhoid  fever  in  this  division.  While  we  did  not  reach 
Chickamauga  in  time  to  inspect  the  regiments  of  this  division,  the 
general  statement  was  made  to  us  that  the  camp  of  the  Eighth  New 
York  was  especially  filthy.  Whether  or  not  the  men  of  this  regiment 
received  the  typhoid  infection  from  the  water  of  the  driven  well 
which  they  used  or  from  wet- weather  springs  we  can  not  say. 

The  following  figures  give  the  principal  facts  concerning  typhoid 
fever  in  this  division: 


Commands. 

Date  of 
first 
case. 

Total 
number 
of  cases. 

Number 
of  rec- 
ognized 
cases. 

Total 
deaths. 

Deaths 

from 

typhoid. 

Per  cent  of 

deaths 

among 

probable 

cases. 

Per  cent  of 
deaths 
among 

recognized 
cases. 

First  Brigade. 
Uih.  New  York 

May  33 
May  31 
June  35 

May  36 
June  1 

233 
316 
350 

167 
161 

95 

46 

147 

56 
46 

31 
14 

18 

38 
31 

24 
11 
17 

32 

30 

10.  .30 
5.09 
6.80 

13.17 
18. 63 

35.36 

1st  Missouri 

6th  Maryland 

23.91 
11.56 

Second  Brigade. 
3d   Nebraska      

39.28 

2d   New  York.... ._. 

1st  District  of  Columbia 

65.21 

Tliird  Brigade. 
3d    Tennessee 

June  9 
May  36 
June  24 

133 

278 
425 

61 

84 

190 

19 
£6 
23 

12 

22 
22 

9.75 
7.91 
5.17 

19.67 

1st  Vermont 

26.19 

8th  New  York 

11.57 

Total  number  of  cases  of  probable  typhoid  fever  in  the  8  regiments  of  this 

division ..._... 1, 853 

Total  number  of  deaths  from  typhoid  in  the  8  regiments 160 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever 8. 63 

Total  number  of  cases  of  recognized  typhoid  fever  in  the  8  regiments  of 

this  division . 725 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever 22. 06 


26 


Summary 

of  deaths  in  the  First  Division 

of  the  Third  Army  Corps 

Commands. 

Total 
deaths. 

Deaths 

due  to 

typhoid 

fever. 

14th  New  York 

First  Brigade. 

31 
14 

18 

24 

1st    Missouri              .      --                     -. ...      ... 

11 

5th  Maryland  - ... 

17 

Second  Brigade. 

63 

53 

28 
31 
25 

22 

2d  New  York _ 

30 

1st  District  of  Columbia            . .                                                        .... 

14 

Third  Brigade. 

84 

66 

3d   Tennessee 

19 
26 
23 

12 

1st  Vermont - - -. 

22 

8th  New  York              -                        ^-     -        

22 

68 

56 

Total  deaths . 215 

Deaths  due  to  typhoid  fever ...      174 

Percentage  of  deaths  from  typhoid  to  total  deaths 80, 93 


CHAPTER  V.  . 

TYPHOID   FEVER   IN  THE   SECOND  DIVISION  OF  THE  THIRD 

ARMY  CORPS. 

Commands. — Second  Kentucky,  Ninth  New  York,  First 
Arkansas,  Fifth  Missouri,  Second  Arkansas,  Sixty-ninth  New 
York,  First  Maine.  Fifty-second  Iowa,  and  First  Mississippi. 

GENERAL   REMARKS. 

When  we  reached  Chickamauga  Park  on  our  round  of  inspection 
(September  10,  1898)  all  the  regiments  of  this  division  with  the  excep- 
tion of  the  Second  Kentucky  and  the  Ninth  New  York  had  already 
departed  from  the  park.  We  have  already  given  a  statement  of  the 
condition  in  which  we  found  the  two  remaining  regiments.  For  the 
following  information  concerning  the  division  as  a  whole  we  are 
indebted  to  the  testimony  of  Maj.  James  M.  Jenne,  chief  surgeon  of 
this  division.  Major  Jenne  reached  Chickamauga  Park  June  11,  and 
acted  as  medical  inspector  until  July  16,  when  he  was  made  chief  sur- 
geon of  the  division.  All  the  regiments  were  on  the  ground  when 
Major  Jenne  arrived.  The  First  Arkansas  was  located  on  very  low 
ground,  while  directly  above  this  regiment  were  the  Ninth  New  York 
and  the  Second  Kentucky.  The  First  Arkansas  was  partially  protected 
from  the  drainage  of  the  other  regiments  by  a  shoulder  of  the  hill  that 
projected  behind  the  officers'  quarters.  The  Second  Brigade  was  situ- 
ated on  the  same  level,  but  farther  south,  with  an  intervening  creek 
which  flowed  only  after  rains.  Overlapping  the  Second  Brigade  and 
extending  beyond  one  of  its  flanks  on  to  higher  ground  was  the  First 
Maine.     The  Fifty-second  Iowa  was  still  farther  south  and  situated 


27 

upon  a  rocky  shoulder  of  ground  quite  elevated  in  some  portions  and 
wholly  denuded  of  soil.  In  this  regiment  the  tents  were  pitched  upon 
the  rocks,  and  the  guy  ropes  were  held  in  position  by  piles  of  rocks. 
The  Mississippi  regiment  was  somewhat  farther  south  and  upon  quite 
low  ground  in  dense  shade.  A  little  stream  coming  from  the  heights 
above  passed  through  this  camp.  This  stream  originated  in  the  Sec- 
ond Brigade.  It  was  only  about  60  paces  from  the  kitchens  of  the 
Fifty-second  Iowa  and  the  nearest  line  officer's  tent  of  the  Third  Ten- 
nessee, which  belonged  to  the  Third  Brigade  of  the  First  Division  of 
the  Third  Army  Corps.  South  of  the  Mississippi  regiment  was  the 
Alexandria  road,  and  on  the  west  of  this  a  small  stream  and  an  open 
field.  On  account  of  the  location,  the  sinks  of  the  Mississippi  regi- 
ment could  not  be  placed  over  30  paces  from  their  company  kitchens 
and -about  the  same  distance  from  other  regiments.  Major  Jenne 
stated  that  he  remembered  going  to  the  camp  of  the  First  Mississippi 
and  pacing  the  ground  from  the  kitchen  to  the  sink,  which  he  found 
to  be  30  paces,  and  the  same  distance  from  the  sinks  of  the  Mississippi 
regiment  to  the  line  officers'  tents  of  the  Third  Tennessee.  In  locat- 
ing the  sinks  of  the  First  Mississippi  it  was  impossible  to  go  farther 
south  or  west  on  account  of  the  little  stream,  which  rapidly  filled  after 
rains,  overflowed  its  banks,  and  flooded  the  woods  for  some  distance. 
If  the  sinks  had  been  dug  to  the  west  in  the  o-pen  field  they  would 
have  been  submerged  at  times  when  the  stream  overflowed.  It  seemed 
necessary  to  locate  the  sinks  where  they  were  placed.  It  will  be  seen 
from  this  that  these  regiments  were  quite  crowded,  that  they  were 
all  located  in  the  woods,  and  that  the  drainage  from  some  of  them 
passed  through  the  sites  of  others.  The  First  Arkansas  received  more 
or  less  of  the  drainage  from  the  Ninth  New  York  and  the  Second  Ken- 
tucky. The  Ninth  New  York  received  in  part  at  least  the  drainage 
of  the  Second  Kentucky. 

When  Major  Jenne  reached  Chickamauga  all  of  the  regiments  were 
using  Chickamauga  Creek  water,  distributed  through  the  commands 
by  means  of  pipes.  Later,  this  water  becoming  suspicious,  some  of 
these  regiments  began  to  draw  water  from  springs,  especially  from 
Blue  Spring  and  Crawfish  Spring.  Water  distributed  through  the 
pipes  was  turbid  and  warm,  inasmuch  as  the  pipes  were  above  the 
ground.  Attempts  were  made,  especially  in  the  First  Maine  and  the 
Fifty-second  Iowa,  to  boil  all  the  drinking  water,  but  according  to 
Major  Jenne  the  supply  of  boiled  water  was  at  no  time  sufficient  and 
the  men  daily  took  water  from  other  sources.  There  was  only  one 
driven  well  near  the  regiments  of  this  division,  and  Major  Jenne  is  of 
the  opinion  that  the  water  from  this  was  not  at  all  times  used.  After 
the  medical  officers  became  suspicious  of  the  Chickamauga  Creek 
water  and  attempted  to  substitute  spring  water  for  it,  there  was  a 
general  shortage  of  drinking  water  on  account  of  there  being  an  insuf- 
ficient number  of  barrels  in  which  it  could  be  transported.  On 
account  of  this  insufficient  supply  of  water  from  the  springs,  men 


28 

contiuued  to  drink  more  or  less  of  the  piped  water  aud  doubtless 
drank  at  times  from  wet-Aveather  springs. 

An  attempt  was  made  to  filter  the  water  for  the  entire  division. 
Each  regiment  was  furnished  \v4th  eleven  pairs  of  Maignem  and  Berke- 
f  eld  filters.  In  the  First  Brigade  these  filters  were  brought  together  at 
one  place  and  an  attempt  was  made  to  filter  enough  drinking  water 
for  the  whole  brigajde.  This  attempt  to  filter  the  water  did  not  prove 
successful.  The  Maignem  filters  soon  became  obstructed  and  many 
of  the  Berkefeld  filters  were  broken.  The  filtering  plant  for  the  First 
Brigade  was  in  charge  of  a  detail  from  the  Ninth  New  York,  and 
within  a  few  days  so  many  filters  were  disabled  or  broken  that  the 
attempt  was  given  up  and  pronounced  a  failure.  In  the  Second  and 
Third  brigades  each  regiment  attempted  to  filter  its  own  water,  but  in 
these  also  the  same  result  was  reached — the  filters  became  clogged, 
manj^  were  broken,  and  the  attempt  was  discontinued.  At  this  place 
we  wish  to  state  that,  in  our  opinion,  for  troops  in.  the  field  all  attempts 
made  to  filter  the  water  by  means  of  the  Maignem  and  Berkefeld  fil- 
ters were  failures.  We  do  not  consider  these  filters  at  all  adapted  to 
this  purpose.  In  permanent  garrisons,  where  the  filters  can  be 
attached  to  hydrants,  they  are  undoubtedly  of  service,  but  in  the 
field,  where  it  frequently  happens  that  water  containing  suspended 
matter  must  be  filtered,  these  filters,  together  or  singly,  have  not  been 
a  success  and  will  not  be  a  sucess.  The  national  encampments  at 
Chickamauga  and  at  Camp  Meade  were  strewn  with  broken  filters 
which  represented  a  large  and  useless  expenditure. 

Major  Jenne  stated  that  throughout  this  division  there  were  numer- 
ous wet-weather  springs  from  which  the  men  frequently  drank.  It 
is  more  than  likely  that  these  springs  account  very  largely  for  the  large 
number  of  cases  and  the  excessive  mortalitj^  from  typhoid  fever  in 
this  division.  As  has  been  already  stated,  some  of  the  regiments  were 
located  upon  rocky  knolls.  The  rains  falling  upon  these  sites  Avashed 
infected  matter  under  the  rocks,  carried  it  some  distance  under  the 
surface  of  the  ground,  and  broke  out  lower  down  the  hillside,  often 
within  other  regimental  encampments  as  wet-weather  springs,  from 
which  the  men  drank  to  a  greater  or  less  extent. 

When  asked  his  opinion  concerning  the  origin  and  spread  of  typhoid 
fever  in  this  division.  Major  Jenne  made  the  following  statement: 

My  belief  is  that  the  Mississippi  regiment  came  to  the  Park  infected  with  typhoid 
fever.  From  the  sinks  of  this  regiment  the  creek  that  flowed  near  by  became  con- 
taminated. This  creek  empties  into  Chickamauga  Creek  only  a  few  feet  below 
the  intake  of  the  general  water  supply  distributed  to  the  regiments.  I  believe 
that  in  this  way  the  general  water  supply  became  contaminated  and  typhoid  fever 
was  spread  throughout  the  division. 

When  asked  if  he  believed  that  the  disease  was  spread  by  means  of 
flies,  he  replied  as  follows: 

Yes;  I  have  no  doubt  that  this  was  one  of  the  most  fruitful  means  of  the  spread  of 
the  disease.  The  sinks  in  some  of  the  regiments  of  this  division,  certainly  during 
the  wet  season,  were  almost  constantly  filled  with  water.    A  great  deal  has  been 


29 

stated  about  the  sinks  not  being  properly  ditched.  This  was  true  in  some  instances, 
but  had  all  the  sinks  been  properly  ditched,  they  would  have  still  filled  with  water 
from  the  bottom  and  the  sides.  When  a  sink  was  dug  soon  after  a  shower  the 
water  would  flow  into  it  like  a  spring.  I  have  seen  this  time  and  time  again;  I 
have  seen  men  digging  sinks  and  the  water  flowing  in  from  the  sides  and  bottoms 
while  they  were  digging.  Water  did  not  soak  into  all  the  sinks.  In  digging  one 
on  the  side  of  a  hill  it  -vyouM  be  likely  to  fill  with  water,  while  another  dug  on  the 
level  might  remain  dry.  There  were  some  sinks  that  gave  me  a  great  deal  of 
trouble.  1  used  a  solution  of  bichloride  of  mercury  and  plenty  of  lime  in  them. 
When  they  were  nearly  full  of  water  and  fecal  matter  I  put  cord  wood  across 
them  and  placed  straw  and  brush  on  the  wood  and  heaped  earth  over  them.  If 
an  attempt  had  been  made  to  fill  these  sinks  in  the  ordinary  way,  the  earth  thrown 
in  would  have  caused  the  contents  to  overflow.  Indeed,  it  is  quite  out  of  the  ques- 
tion to  throw  earth  into  these  sinks,  because  it  displaces  the  water.  It  was  the 
practice  to  put  staw  in  them  from  the  corrals  and  burn  them  out.  Some  of  the  sinks 
were  situated  on  sharp  inclines  and  during  rains  they  would  fill,  overflow,  and  run 
down  the  hillsides,  sometimes  through  the  camp.  There  were  three  regiments 
situated  one  after  the  other  passing  down  the  hill,  so  that  whatever  wash  there 
was  from  their  sinks  and  the  regiment  above  came  to  them.  These  were  the 
First  Mississippi,  the  Fifty- second  Iowa,  and  the  First  Maine.  Of  these  three 
regiments  the  Fifty-second  Iowa  occupied  the  highest  ground,  and  the  flow  from 
this  site  was  in  one  direction  toward  the  First  Maine  and  in  the  other  direction 
toward  the  First  Mississippi.  The  Third  Tennessee  was  farther  up  the  hill.  All 
of  these  regiments  were  closely  crowded  together. 

In  regard  to  the  hospital  of  this  divison  Lieutenant-Colonel  Wood- 
hull,  in  his  report  already  referred  to,  makes  the  following-  statement: 

Nearly,  if  not  all,  of  the  regiments  in  this  division  maintain  regimental  hos- 
pitals. For  instance,  the  Ninth  New  York  has  from  6  to  8  men  in  a  local  hospital 
out  of  60  supposed  to  be  in  quarters.  In  the  division  hospital  are  33.  The  regi- 
ment has  had  about  80  cases  of  typhoid,  but  the  proportion  of  malarial  cases  is 
not  large.  First  Arkansas  has  37  in  hospital  and  85  in  quarters.  When  exam- 
ined there  was  a  small  regimental  hospital  maintained  by  individual  subscription, 
in  which  were  3  cases  of  dysentery  alleged  to  have  been  retiirned  from  the  division 
hospital.  First  Maine  has  7  men  in  the  regimental  hospital.  Of  the  42  officers,  7, 
or  16.67  per  cent,  are  sick,  all  with  typhoid  fever. 

The  hospital  of  this  division  (Major  Bradbury,  First  Maine,  in  charge)  consists 
of  37  hospital.  8  conical,  and  6  common  tents,  containing  285  cots  and  250  patients. 
Eight  medical  officers  are  preseut  for  duty,  with  6  stewards  and  138  privates.  Of 
the  latter,  45  were  men  of  the  line  detailed  from  regiments.  To  this  date,  August 
7,  1898,  1,190  patients  have  passed  through  the  hospital,  and  56  typhoid  cases  were 
present.  Were  all  the  men  in  the  division  who  should  be  in  hospital  present  it 
would  be  overcrowded,  as  it  has  been  when  men  were  at  times  literally  upon  the 
ground,  and  at  other  times  medical  officers  have  given  up  their  own  accommoda- 
tions to  them.  Sometimes  typhoid  patients  are  returned  to  their  regiments  for 
convalescence  in  order  to  make  room.  Speaking  generally  the  condition  of  the 
hospital  is  very  good.  The  streets  are  broad  and  well  policed;  the  general  police 
is  excellent;  the  ordinary  wards  are  very  good,  but  the  typhoid  ward  is  too 
crowded  and  formerly  was  still  more  so  when  the  cots  touched  each  other. 

There  is  great  difficulty  in  disinfecting  the  bedding.  The  hospital  is  brigaded 
but  not  the  attendants,  and  there  would  be  difficulty  were  the  command  suddenly 
broken  up.  There  are  several  brigade  surgeons  at  this  hospital  and  it  is  plain 
that  they  do  not  regard  that  as  their  proper  sphere.  The  records  are  well  kept, 
but  great  difficulty  is  experienced  in  obtaining  supplies.  This  seems  to  be  partly 
technical  and  partly  from  Instifficient  stores.     I  examined  the  record  of  a  requisi- 


30 


tiou  made  on  the  1st,  acted  on  on  the  13th,  ITth,  and  19th,  and  on  the  22d  filled  in 
part.  I  saw  another  where  two  articles  were  supplied  ont  of  seventeen  authorized. 
The  hospital  finds  it  practically  impossible  to  get  intestinal  antiseptics,  such  as 
salol,  or  strychnia,  or  subgallate  of  bismuth.  It  is  very  largelj^  dependent  upon 
regimental  and  Red  Cross  funds,  and  a  case  of  boxes  to  hold  regimental  supplies 
has  been  arranged  to  stimulate  regimental  interest,  which  is  quite  foreign  to  the 
principle  of  these  organizations.  The  Red  Cross  supplies  1.500  pounds  of  ice 
daily;  milk,  food,  comforts,  and  some  absolute  necessities,  as  medicines  themselves. 

The  following  figures  give  the  most  important  facts   concerning 
typhoid  fever  in  this  division : 


Commands. 

Date  of 
first 
case. 

Total 
number 
of  cases. 

Total 
number 
of  recog- 
nized 
cases. 

Total 
deaths. 

Deaths 

from 

typhoid. 

Per  cent 
of  deaths 

among 
probable 

cases. 

Per  cent 
of  deaths 

among 

recognized 

cases. 

First  Brigade. 
2d    Kentucky 

June  26 
June  10 
June   2 

June   6 
June   4 
June  13 

June  25 
June  8 
June   1 

.       286 
323 

228 

212 

287 
299 

188 
345 
397 

87 

139 

83 

51 
95 

191 

88 
184 
98 

30 
46 
23 

16 
26 
25 

45 
37 
.S3 

28 
46 
19 

14 
17 
23 

45 
36 
29 

9.79 
14.24 
8.33 

6.60 
5.92 
7.69 

23.93 

10.4.? 

7.30 

32.18 

9th  jSTew  York 

33.09 

1st  Arkansas 

22.89 

Second  Brigade. 
5th  Missouri        

27.45 

2d    Arkansas.  

17.89 

69th  New  York 

12.04 

Third  Brigade. 
1st  Maine   

51.13 

19.56 

1st  Mississippi 

29.59 

Total  number  of  cases  of  typhoid  fever  in  the  nine  regiments  of  this  division.  2, 565 
Total  number  of  deaths  from  typhoid  fever  in  the  nine  regiments  of  this 

division .    .  _ 257 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever 10. 02 

Total  number  of  cases  of  recognized  typhoid  fever  in  the  nine  regiments  of 

this  division   ..     ._     ---   _.-- . --.   1,016 

Percentage  of  deaths  among  recognized  cases  of  tjrphoid  fever 25. 29 

Summary  of  deaths  in  the  Second  Division  of  the  Third  Army  Corps. 


Commands. 

Total 
deaths. 

Deaths 

due  to 

typhoid 

fever. 

First  Brigade. 

30 
46 
23 

28 

9th  New  York                                                 .                - - 

46 

19 

Total 

99 

93 

Second  Brigade. 

16 
26 
25 

14 

17 

69thNewYork           .  ---     -   

23 

Total 

67 

54 

Third  Brigade. 

1st  Maine 

45 
37 
33 

45 

36 

1st  Mississippi -- - --  .-.  .    - 

29 

Total 

115 

110 

Total  deaths 281 

Deaths  due  to  typhoid  fever 257 

Percentage  of  deaths  from  typhoid  to  total  deaths. 91. 45 


31 

Colonel  Hoff,  chief  surgeon  of  this  corps,  has  furnished  us  with  con- 
siderable valuable  information  concerning  sickness  in  it.  Colonel 
Hoff  reported  for  duty  at  Chickamauga  Park  May  25,  1898,  and 
remained  with  this  corps  during  its  stay  there.  When  asked  to  give 
his  opinion  concerning  the  introduction  of  typhoid  fever  in  this  corps, 
Colonel  Hoff  responded  as  follows : 

Typhoid  fever  was  brought  in  in  the  very  beginning  with  the  troops.  I  speak 
now  particularly  of  the  Third  Corps  with  the  history  of  which  I  am  familiar  from 
the  date  of  its  organization.  Three  regiments  joined  the  Second  Division  of  the 
Third  Corps  about  the  latter  part  of  .May  or  early  in  June,  and  these  regiments 
came  on  the  ground  with  what  was  practically  a  disabling  sick  list.  These  three 
regiments  were  the  First  Mississippi  and  the  First  and  Second  Arkansas.  The 
record  of  the  First  Mississippi  begins  on  the  12th  of  June,  and  total  of  sick  reported 
for  that  day  was  64.  This  number  did  not  include  all  of  those  actually  sick. 
There  was  a  large  number  in  the  regiment  who  were  sick,  but  who  were  not 
reported  at  that  time.  You  will  see  (referring  to  a  chart  showing  the  curve  of 
sickness  in  this  regiment)  as  we  go  on  we  come  to  a  very  remarkable  upshoot  on 
the  30th  day  of  June.  This  remarkable  upshoot  is  due  to  the  fact  that  that  regi- 
ment was  vaccinated  at  this  time.  There  were  100  or  more  men  suffering  from 
the  effects  of  vaccination,  so  this  upward  move  of  the  curve  must  be  regarded  as 
only  an  incident.  It  will  be  seen  that  this  upward  turn  reached  its  maximum  on 
July  2.  After  this  there  was  a  gradual  subsidence  until  the  sick  report  went  down 
to  about  what  it  was  in  the  beginning,  showing  85  men  on  the  sick  report  on  the 
7th  day  of  July.  From  the  latter  date  on  the  sick  list  increased,  as  you  see,  with 
considerable  rapidity,  reaching  the  maximum  on  August  20,  on  which  date  the 
total  on  sick  call  numbered  210.  From  August  20  to  September  9,  when  the  First 
Mississippi  left  Lauderdale,  the  sick  curve  declined.  This  is  in  part  due  to  the 
fact  that  men  were  sent  home  on  sick  furlough  and  were  not  carried  on  the  sick 
report.  It  does  not  necessarily  indicate  diminished  sickness.  The  Arkansas  regi- 
ments came  into  this  camp  in  practically  the  same  condition  as  did  the  Mississippi 
regiment. 

It  should  be  understood  that  in  the  above  statement  Colonel  Hoff 
was  speaking  of  total  sickness  and  not  of  typhoid  fever  especially. 
He  convinced  us  that  these  three  regiments  came  to  Chickamauga 
with  a  high  sick  list  and  continued  in  this  condition  throughout  their 
stay.  It  will  be  seen  by  reference  to  the  tables  already  given  that  of 
the  regiments  of  the  Second  Division  of  this  corps  (excluding  the 
Sixty-ninth  New  York,  which  remained  at  Chickamauga  Park  for 
only  a  few  days)  all  except  the  Second  Kentucky  and  the  First  Maine 
reached  Chickamauga  Park  infected  with  typhoid  fever,  while  of 
those  of  the  First  Division  (excluding  the  Fifth  Maryland,  which 
remained  at  Chickamauga  Park  for  only  a  few  days)  all  reached  the 
park  infected  with  typhoid  fever  with  the  exception  of  the  Eighth 
New  York. 

Continuing  his  testimony,  Major  Hoff  stated: 

The  Fifty-second  Iowa  and  the  First  Maine  reached  the  park  in  excellent  con- 
dition. Going  over  the  First  Division,  the  Second  Nebraska,  Second  Missouri, 
and  Fourteenth  New  York  came  in  excellent  shape.  The  Eighth  New  York  had 
a  doubtful  record  so  far  as  is  indicated  by  total  sickness  from  the  very  beginning. 
Typhoid  fever  gradually  spread  from  the  intected  regiments  and  soon  there  were 


32 

cases  in  everj-  regiment  of  the  corps.  By  the  middle  of  July  or  earlier  all  regi- 
ments were  reporting  a  few  cases  of  typhoid  fever,  but  it  conld  be  called  epidemic 
only  in  the  three  regiments  mentioned  (First  Mississippi,  First  and  Second 
Arkansas).  In  most  of  the  regiments  at  that  time  typhoid  fever  was  scarcely 
recognized,  most  of  the  cases  being  designated  as  "malaria."  Up  to  the  middle 
of  August,  possibly  later.  I  believe  that  the  infection  was  spread  by  means  of 
flie.~.  I  believe  the  water  supply  became  infected  about  the  latter  part  of  July, 
and  from  that  time  on  there  was  a  decided  rise  until  it  culminated  about  August  20. 

Colonel  Hoff  believed  that  the  general  water  supply  taken  from 
Chickamauga  Creek  became  contaminated  by  the  drainage  from  the 
camps,  but  that  water  contamination  was  not  confined  to  this  source. 

He  stated: 

I  thought  that  every  spring  and  every  well,  or  almost  all,  in  the  park  must  have 
partaken  of  the  infection.  This  is  only  an  opinion,  but  the  fact  that  we  had  an 
extraordinary  and  widespread  morbidity  leads  to  the  inference  that  there  must 
have  been  some  common  cause. 

When  asked  about  the  first  case  of  typhoid  fever,  Colonel  Hoff 
stated : 

The  first  case  of  typhoid  fever  that  was  diagnosticated  appeared  in  the  Second 
Division  hospital  about  June  15.  It  appeared  about  the  time  when  the  cases  began 
to  be  carefully  investigated.  The  hospital  opened  about  June  10,  but  it  was  not 
in  running  order  until  about  June  15.  and  I  have  no  doubt  that  had  a  careful 
investigation  been  made  earlier  cases  of  typhoid  fever  would  have  been  recog- 
nized before  the  time  given.  It  is  difficult  for  anyone  who  has  not  been  through 
it  to  understand  what  a  herculean  task  it  was  to  introduce  even  the  simplest  form 
of  reports  among  these  organizations.  We  asked  the  regimental  officers  to  report 
to  us  every  day  the  number  of  people  excused  from  duty,  and  we  insisted  upon  this 
report.  After  receiving  it.  1  fre'iuently  sent  an  inspector  around  to  find  out 
how  the  consolidated  report  agreed  with  the  regimental  reports,  and  I  would  nften 
find  a  difference  of  50  or  60  between  the  reports.  These  inaccuracies  were  not 
confined  to  the  medical  department.  It  frequently  happened  that  the  consolidated 
monthly  report  showed  a  loss  of  more  than  1 .000  men.  We  kept  no  specific  account 
of  typhoid  fever.  We  had  a  general  record  of  the  morbidity  without  reference  to 
any  one  disease.  There  were  many  cases  of  measles  and  mumps,  and  a  good  many 
cases  of  fever  diagnosticated  as  ■•  ma  arial  fever."'  A  few  of  the  cases  were  diag- 
nosticated as  "typhoid  fever,"  but  the  latter  were,  in  proportion  to  the  whole, 
comparatively  rare. 

When  asked  if  he  could  ajjproximate  the  date  on  which  he  believed 
the  general  water  supply  became  infected,  Colonel  Hoff  stated: 

I  should  say  about  July  20.  judging  from  the  rapid  advance  of  the  disease  from 
that  time.  1  do  not  mean  to  say  that  the  number  of  cases  began  to  increase  imme- 
diately after  July  20,  but  that  the  increase  was  more  marked  two  or  three  weeks 
after  this  date,  and  this  is  the  reason  why  I  believe  that  there  must  have  been 
some  infection  about  that  time  from  some  source  that  was  capable  of  producing  a 
general  infection.  The  water  supply  was  the  only  thing  the  regiments  were  using 
in  common.  The  advance  of  the  disease  so  lar  as  the  First  Division  of  the  Third 
Army  Corps  is  concerned  was  exceedingly  slow.  This  division  always  had  a  lower 
curve  than  the  Second  Division,  but  the  two  curves  went  up  simultaneously. 


33 

Colonel  Hoff  ayrs  of  the  opinion  that  the  Second  Division  suffered 
more  heavih*  than  the  First  on  account  of  the  presence  in  the  Second 
Division  of  the  three  highly  infected  regiments.  He  also  believed 
that  the  infection  spread  from  the  Second  Division  through  the  First, 
notably  through  the  Third  Brigade  of  the  First  Division,  which  was 
encamped  very  near  the  Third  Brigade  of  the  Second  Division. 

The  following  figures  show  the  relative  prevalence  of  typhoid  fever 
and  the  mortality  from  this  disease  in  the  two  divisions  of  the  Third 
Army  Corps: 

Total  number  of  cases  of  probable  typhoid  fever  in  8  regiments  of  the  First 

Division _._.. 1,853 

(It  will  be  seen  that  this  includes  the  Second  New  York,  which  remained 
at  Chickamauga  only  12  daj^s.) 

Total  number  of  cases  of  jjrobable  typhoid  fever  in  the  9  regiments  of  the 
Second  Division .,. 2,565 

Tolal  number  of  deaths  from  typhoid  fever  in  8  regiments  of  the  First 
Division . . . .   _ .     _ .    _ 160 

Total  number  of  deaths  from  typhoid  fever  in  the  9  regiments  of  the  Second 
Division . .  I . . . 257 

Percentage  of  deaths  among  jprobable  cases  of  typhoid  fever  in  8  regiments 
of  the  First  Division 8.63 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  in  the  9  regi- 
ments of  the  Second  Division 10. 01 

Total  number  of  cases  of  recognized  typhoid  fever  in  8  regiments  of  the 
First  Division    .  _    ... ,  _ . 725 

Total  number  of  cases  of  recognized  typhoid  fever  in  the  9  regiments  of  the 
Second  Division  .. 1,016 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever  in  8  regiments 
of  the  First  Division 22.06 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever  in  the  9  regi- 
ments of  the  Second  Division  _ .   .   ..    25.29 

Aggregate  strength  of  the  8  regiments  in  the  First  Division 9, 444 

Aggregate  strength  of  the  9  regiments  in  the  Second  Division 11, 124 

Percentage  of  cases  of  probable  typhoid  fever  in  8  regiments  of  the  First 
Division . .._ 19.62 

Percentage  of  cases  of  probable  typhoid  fever  in  the  9  regiments  of  the 
Second  Division _ 23. 06 

It  will  be  seen  from  these  figures  that  typhoid  fever  was  both  abso- 
lutely and  relatively  more  prevalent  in  the  Second  Division  than  in 
the  First  Division  of  this  corps. 

Aggregate  strength  of  the  17  regiments  of  this  corps 20, 568 

Total  number  of  cases  of  probable  typhoid  fever  in  the  17  regiments  of  this 
corps .. ..    4,418 

Percentage  of  cases  of  probable  typhoid  fever  in  the  17  regiments  of  this 
corps... ... .......     21.47 

Total  number  of  deaths  from  typhoid  fever  in  the  17  regiments  of  this 
corps . .    417 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  in  the  17  regi- 
ments of  this  corps 9.43 

7273 3 


34 

The  following  table  will  show  the  morbidity  and  mortality  from 
typhoid  fever  in  the  Thii'd  Army  Corps : 


Commands. 


Mean 
strength. 


Cases  of  typhoid 
fever. 


Certain. 


Certain 

and 

probable. 


Deaths 
from 

typhoid 
fever. 


Deaths 
from  all 
diseases. 


FIRST   DIVISION. 

14th  iSTew  York 

1st  Missouri  _ 

5th  Maryland 

2d    Nebraska 

2d    New  York 

3d    Tennessee 

1st  Vermont _- 

8th  New  York 

Total 

SECOND   DIVISION. 

2d   Kentucky , 

9thNew  York 

1st  Arkansas 

5th  Missouri ..- 

2d   Arkansas 

69th  New  York 

1st  Maine... 

52d   Iowa 

1st  Mississippi 

Total 

Total  Third  Army  Corps 


1.377 

1,275 

985 

1.303 

i;oi4 

1,293 

996 

1,301 


95 
46 

147 

.   56 

46 

61 

84 

190 


233 
216 

250 
167 
161 
123 

278 
425 


31 
14 
18 
26 
31 
19 
26 
23 


9,444 


1,8.53 


160 


188 


1,3B2 
1,292 
1,290 
1,274 
1.291 
1,026 
1,286 
1,304 
1,029 


87 
139 
83 
51 
95 
191 
88 
184 


286 
323 
228 
212 
287 
299 
188 
345 
397 


11,124 


1,016 


2, 565 


20,568 


1,741 


4,418 


-  417 


281 
"469 


Deaths    from 
typhoid    fever 
in  100  cases  of — 

Percent- 
age of 
deaths 
from 
typhoid 
to  deaths 
from  all 
diseases. 

Morbidity    of 
typhoid    fever 
in    1.000    mean 
strength— 

Deaths 

from 

typhoid 

Commands. 

Certain 
typhoid. 

Certain 

and 
probable. 

For  cer- 
tain 
cases  of 
typhoid. 

For  cer- 
tain and 
probable 
cases  of 
typhoid. 

fever  in 
1,000  of 
mean 

strength. 

FIRST  DIVISION. 

14th  New  York 

25.26 
23.91 
-      11.  .56 
39.28 
65. 21 
19.65 
26.19 
11.57 

10.30 
5.09 
6.80 
13.17 
18.63 
9.75 
7.91 
5.17 

77.41 
78.57 
94.44 
84.61 
96.77 
63.15 
84.61 
95. 65 

74.39 
36.07 

149.23. 
42.97 
45.36 
47.17 
84.33 

146.04 

182.45 
169. 41 
253. 80 
127. 39 
158.  77 
95. 12 
279  11 
318. 98 

18.79 

8.63 

5th  Maryland _ 

2d    Nebraska 

17.25 
16.88 

29.58 

9.28 

1st  Vermont     

22.08 

8th  New  York 

16.91 

Total 

22.06 

8.63 

85. 10 

76. 76 

196.20 

16.94 

SECOND   DIVISION. 

32.18 
33.09 
22.89 
27.45 
17.89 
12.04 
51.13 
19.56 
29.59 

9.79 

14.24 

8.33 

6.60 

5.92 

7.69 

23.93 

10.43 

7.30 

93.33 

100 
82.60 
87.50 
6.5.39 
92 

100 
97.29 
87.87 

65.31 
107.  58 
64.34 
40.03 
73.58 
186. 15 
68.42 
141. 10 
95.23 

.     214. 71 
250 
176. 74 
166. 40 
232.30 
291. 42 
146.19 
264.  57 
385. 81 

21.03 

9th  New  York 

1st  Arkansas 

35.60 
14.73 

10.99 

2d    Arkansas 

69th  New  York 

13. 16 
23.41 

1st  Maine 

34.99 

52d   Iowa 

27.60 

1st  Mississippi 

28.18 

Total 

25.29 

10.01 

91.45 

91.33 

230.58 

23.10 

Total  Third  Army  Corps .  _ 

23.95 

9.43 

88.91 

84.64 

214.79 

20.27 

35 
CHAPTER  VI. 

GENERAL  REMARKS  CONCERNING  TYPHOID  FEVER  IN  THE 
FIRST  AND  THIRD  ARMY  CORPS. 

Site. — The  surface  of  Chickamauga  Park  is  gently  rolling,  with, 
sufficient  grade' to  carry  away  the  heaviest  rainfalls.  There  are  no 
morasses  or  swamps  within  the  park.  The  surface  is  partly  cleared 
and  partly  wooded,  but  everywhere  the  undergrowth  has  been  cut  out 
and  there  is  nowhere  dense  forest.  In  some  places  local  areas  are 
somewhat  flat  and  may  be  damp  during  a  rainy  season;  especiall}^  is 
this  true  when  the  flat  surface  is  covered  with  woods.  With  the 
exception  of  such  localities  as  these  there  is  no  part  of  the  park  where 
an  excellent  site  for  a  regimental  camp  might  not  be  secured.  Most 
of  the  little  streams  that  drain  the  park  are  dry  except  after  rains. 
However,  some  of  them  are  fed  by  springs  and  flow  continuously. 
Most  of  the  drainage  from  the  park  passes  ultimately  into  Chicka- 
mauga Creek,  which  flows  along  the  southeastern  border.  A  large  part 
of  the  i^ark  is  covered  with  magnesian  limestone,  upon  which  there 
has  been  deposited  gravel,  which  varies  in  depth  from  a  few  inches 
to  manj^  feet.  The  strata  of  this  limestone  have  been  broken  and 
thrown  into  ridges  which  dip  at  various  angles.  The  outcropping 
rock  is  in  many  places  broken  and  fissured  in  every  direction,  so  that 
water  easil}^  percolates  through  the  crevices  and  between  the  layers, 
frequently  appearing  on  the  surface  and  forming  wet- weather  springs. 
When  the  water  penetrates  greater  masses  of  rock  and  passes  for 
greater  distances  under  the  surface  and  accumulates  in  larger  vol- 
ume, permanent  springs  are  formed.  So  far  as  the  surface  and  soil 
are  concerned  there  is  only  one  objection  to  Chickamauga  Park  as  an 
encampment  for  a  large  body  of  troops.  This  objection  lies  in  the 
difiiculty  universall}^  experienced  in  the  summer  of  1898  in  digging 
sinKs  of  sufficient  size  and  depth  and  in  having  proper  material  with 
which  the  contents  of  these  sinks  could  be  covered.  In  many  places 
the  magnesian  limestone  lies  directly  on  the  surface.  Pits  could  be 
made  only  by  blasting,  and  when  thus  made  were  of  insufficient  size 
and  could  not  be  properly  cared  for. 

It  is  a  matter  of  some  surprise  that  so  many  of  the  regiments 
located  at  Chickamauga  should  have  encamped  in  the  wooded  x^or- 
tions.  However,  as  has  been  stated,  the  woods  were  not  dense  any- 
where, the  undergrowth  having  been  cut  out  so  that  it  was  easy  to 
drive  a  team  through  any  of  the  wooded  portions  of  the  park.  There 
were  some  reasons  for  the  regiments  locating  in  the  wooded  rather 
than  in  the  open  spaces.  In  the  first  place  many  of  the  regular  regi- 
ments were  temporarily  encamped  in  the  park  during  April,  1898, 
before  the  arrival  of  the  volunteer  regiments.  The  regular  troops 
left  the  park  late  in  April  or  early  in  May,  and  most  of  these  regiments 
went  to  Cuba.     The  volunteer  regiments  on  arriving  found  that  the 


36 

most  desirable  sites  in  tlie  open  portions  of  the  park  had  already  been 
occupied  by  the  regular  commands.  Recognizing  the  fact  that  it  was 
not  safe  to  occupy  sites  so  recentl}^  vacated  bj'  other  regiments,  the 
volunteers  felt  compelled  in  many  instances  to  locate  in  the  woods. 
In  the  second  place,  the  open  spaces  were  reserved  in  part  for  drill 
grounds.  There  were  dail}^  regimental  and  brigade  drills  and  less 
frequently-  division  and  corps  exercises.  Thirdly,-  some  of  the  open 
fields  had  been  leased  from  the  Government  by  individuals,  who 
refused  to  allow  the  troops  to  occuj)y  these  lands.  This  necessitated 
negotiations,  which  took  time,  and  in  the  meanwhile  the  regiments 
encamped  in  the  woods.  However,  we  do  not  think  that  a  great  deal 
of  stress  should  be  laid  upon  the  fact  that  the  regiments  were  encamped 
in  the  woods.  As  has  been  already-  stated,  these  woods  were  well 
lighted  and  jDenetrated  by  the  rays  of  the  sun  in  every  part.  It  is 
possible  that  the  site  of  the  First  Mississippi  Volunteer  Infantry  was 
in  a  space  too  densely  wooded. 

So  far  as  the  locations  of  the  camps  are  concerned,  there  is  one  criti- 
cism that  must  be  made  by  anj-one  who  knows  anything  of  the  sanita- 
tion of  camps.  There  is  no  adequate  reason  why  the  regimental  camp 
sites  in  Chickamauga  Park  should  not  have  been  changed  every  three 
weeks,  and  yet  it  is  a  fact  that  many  a  tent  pitched  there  in  Maj'  was 
not  moved  until  the  regiments  dispersed  late  in  August.  The  recoi-ds 
show  that  regimental  medical  officers  petitioned  time  and  time  again 
for  a  change  in  camp  sites  and  that  such  petitions  were  in  many 
instances  wholh'  ignored.  Eveiyone  versed  in  camp  sanitation  knows 
that  under  the  very  best  conditions  any  given  site  will  become  more 
or  less  contaminated  when  occupied  for  a  few  weeks,  and  it  is  strange 
that  the  desirability  of  frequent  changes  in  camp  sites  in  Chicka- 
mauga Park  during  the  summer  of  1898  was  not  recognized  and  acted 
upon  by  superior  line  officers. 

On  account  of  the  rolling  character  of  the  surface  and  the  geological 
formation  already  described,  it  sometimes  happened  that  one  regiment 
had  its  health  endangered  by  drainage  from  other  regiments.  This 
was  so  i)lainl3''  the  case  in  the  Second  DiAdsion  of  the  Third  Army 
Corps  that  it  is  strange  that  it  was  not  earl}^  recognized  and  that  the 
camps  of  some  of  the  regiments  were  not  changed. 

Drainage. — As  has  already  been  stated,  nearly  QYery  acre  in  the 
park  is  jjrovided  with  such  excellent  natural  drainage  that  the  excess 
of  water  falling  upon  it  in  the  heaviest  rain  is  soon  removed.  Numer- 
ous small  streams  wind  among  the  slightly  elevated  knolls  and  act  as 
natural  sewers.  One  of  the  larger  of  these  streams,  known  as  Cave 
Spring  Branch,  through  its  tributaries  receives  the  drainage  of  a  large 
portion  of  the  area  covered  by  the  encampments.  This  stream  flows 
into  Chickamauga  Creek,  and  the  relation  of  the  junction  of  these  two 
streams  to  the  intake  of  the  general  water  supply  will  be  discussed 
later.     On  account  of  the  variations  in  dip  of  the  layers  of  limestone, 


37 

and  also  on  acconnt.  of  the  crevices  in  the  layers  of  this  stone,  the 
drainage  is  not  always  on  the  surface.  Water  falling  on  an  elevated 
area  in  the  park  in  part  passes  down  between  the  tilted  and  broken 
layers  of  limestone  and  reaches  the  surface  at  the  foot  of  the  hill.  If 
the  distance  under  ground  traversed  by  the  percolating  water  is  short 
and  the  depth  of  penetration  is  not  great,  a  wet- weather  spring  results; 
on  the  other  hand,  if  a  larger  volume  of  water  accumulates  under  the 
ground  and  percolates  to  a  greater  distance,  a  permanent  spring 
results.  The  layers  of  limestone  rock  vary  much  in  thickness.  In 
many  places  they  are  superimposed  one  directly  upon  the  other;  in 
other  localities  the  layers  are  separated  by  deposits  of  clay  almost  as 
hard  as  the  rock  itself,  so  that  in  drilling  there  is  no  noticeable  differ- 
ence between  the  rock  and  clay.  For  the  reasons  already  given,  the 
waters  of  manj^  of  the  smaller  springs,  of  some  of  the  larger  ones  and 
of  some  of  the  wells,  became  more  or  less  turbid  after  heavy  rains. 
This  can  be  accounted  for  only  hy  contamination  with  surface  drain- 
age. It  will  be  readily  seen  that  with  the  conditions  as  here  described 
a  polluted  surface  necessarily  led  to  polluted  springs  and  wells. 

Water  supply. — Through  and  about  the  park  are  numerous  large 
springs,  supplying  an  almost  unlimited  quantity  of  water,  which  is 
apparenth^  of  the  verj^  best  quality.  Undoubtedlj^,  when  there  is  no 
unusual  surface  pollution  about  them,  the  water  from  any  and  all  of 
these  springs  is  quite  safe.  However,  the  largest  of  them  may  be  con- 
taminated to  a  greater  or  less  extent  hj  surface  drainage.  Crawfish 
Spring,  the  flow  of  which  is  estimated  at  60,000,000  gallons  per  day, 
sometimes  becomes  muddy  after  heavy  rains.  In  its  normal  state 
this  is  one  of  the  most  beautiful  springs  in  the  world.  JSTumerous 
large  springs,  such  as  Sweet  Spring,  Blue  Spring,  Georgia  Mineral 
Spring,  Rossville  Spring,  etc.,  located  outside  of  the  park,  furnished 
drinking  water  for  the  troops.  From  most  of  these  springs  water  was 
dipped  in  pails,  the  ma^n  dipping  the  water  standing  upon  the  edge  of 
the  spring  and  with  the  water  often  undoubtedlj^  falling  over  his  boots 
and  possibly  contaminating  the  source  of  supply.  The  water  was 
hauled  to  the  camps  from  these  springs  in  headless  barrels.  The  bar- 
rels were  deposited  in  the  camp,  and  men  dipped  with  clean  and 
unclean  cups,  possibl}^  with  clean  and  unclean  hands,  water  from 
these  barrels  and  drank  it.  It  must  be  admitted  that  the  possibilities 
of  occasional  contamination  of  portions  of  the  water  obtained  in  this 
way  were  not  insignificant. 

We  have  already  referred  to  the  wet-weather  springs.  We  are 
quite  confident  that  these  were  a  means  of  infection.  Especially  do 
we  believe  that  this  was  true  in  the  Second  Division  of  the  Third  Army 
Corps.  The  location  of  some  of  the  regiments  of  this  corps  was  such 
that  the  contamination  of  wet-weather  springs  breaking  out  from  the 
base  of  hills  occupied  by  them  was  almost  absolutelj^  certain. 

There  are  numerous  wells  throughout  the  park.     These  differ  con- 


38 

siderably  in  constmetion.  It  is  generally  believed  that  all  of  the  wells 
in  the  i^ark  are  driven  ones.  However,  we  have  already  seen  from 
the  testimony  of  Major  Hysell  that  this  is  not  true  of  Jay's  Mill  well. 
In  regard  to  the  wells  General  Boynton,  chief  commissioner  of  the 
park,  made  this  statement  to  us : 

We  had  nine  driven  wells  here  when  the  troops  began  to  arrive.  These  had 
heen  in  nse  two  or  three  years.  Soon  we  saw  that  the  supply  from  these  would 
be  insnfQcient.  We  obtained  five  drilling  machines  and  began  to  put  down  wells 
as  fast  as  we  could  wherever  they  were  wanted.  Most  of  this  drilling  was  done 
before  the  rainy  season  set  in.  In  boring  for  these  wells  we  x)assed  through  gravel 
and  loose  rock  near  the  surface,  then  we  struck  very  solid  rock,  which  ranged  in 
thickness  from  80  to  164  feet.  A  few  of  the  wells  are  bored  through  less  than  80 
feet  of  rock,  while  others  are  carried  through  164  feet  of  rock.  In  drilling  there 
is  no  evidence  of  cavities.  The  water  flows  in  when  we  get  down  to  what  we  call 
the  water-bearing  stratum.  Usually  while  boring  it  is  found  necessary  to  pour 
water  into  the  hole  to  facilitate  the  action  of  the  drill.  After  the  water-bearing 
stratum  has  been  reached,  the  water  rises  to  within  10  feet  of  the  surface,  some- 
times nearer.  For  instance,  the  well  at  the  McDuffield  place,  which  is  168  feet 
deep,  was  perfectly  dry  through  164  feet  of  rock,  and  immediately  as  soon  as  we 
got  to  the  water-bearing  stratum  it  came  up  to  within  4  feet  of  the  surface.  At 
the  Brotherton  place  the  well  is  125  feet  deep,  and  most  of  it  through  solid  rock, 
and  the  water  goes  to  within  4  feet  of  the  surface. 

We  found  considerable  diversity  of  statement  concerning  the 
inquiry  as  to  whether  or  not  the  water  from  these  driven  wells  became 
cloudy  after  hea^^y  rains.  General  Boynton  stated  this  occurred  in 
only  three  wells  within  the  park.  He  thought  that  in  the  case  of 
these  it  could  be  explained  only  by  contamination  with  surface  drain- 
age. Others  stated  that  many  of  the  wells  in  the  park  furnished  tur- 
bid water  after  hea\^  rains.  We  think  that  there  can  be  no  doubt 
that  there  must  have  been  surface  contamination  of  at  least  some  of 
these  wells,  and  possibly  the  water  from  these  may  have  served  as  a 
factor  in  the  distribution  of  tj^phoid  fever.  The  construction  of  these 
driven  wells  was  apparently  Yerj  good.  The  drill  made  an  opening 
of  a  little  more  than  6  inches  in  diameter  through  the  solid  rock.  Into 
this  hole  a  wrought-iron  casing  was  driven  to  a  sufficient  depth  to 
make  it  water-tight.  The  casing  above  the  rock  was  then  set  in 
hydraulic  cement.  ISTotwithstanding  this  care  there  can  be  no  doubt, 
as  above  stated,  that  the  water  did  occasional!}^  become  turbid,  and 
when  this  happened  the  only  explanation  i^ossible  is  that  the  turbidity 
was  due  to  surface  drainage. 

In  addition  to  the  above-mentioned  sources,  water  was  pumped 
from  Chickamauga  Creek  and  distributed  by  means  of  pipes  through 
the  various  organizations  encamped  in  Chickamauga  Park.  The  only 
troops  that  did  not  receive  piped  water  from  Chickamauga  Creek  was 
the  Second  Division  of  the  First  Army  Corps.  Jhe  regiments  of  this 
division  were  located  quite  distant  from  any  of  the  pipes,  and  this 
water  could  have  been  used  by  men  belonging  to  this  division  only 


39 


occasionally.     The  intake  of  the  water  supply  from  Cliickamauga 
Creek  was  most  unfortunate,  as  shown  by  the  following  illustration: 

r  •  ,    I         r  /  /       Or/dina/  inflow. 

Inspection  of  intaKe  of  /  /       / 

wafer  from  Chickamau^a        /  /i  ¥- 

Creek.  /  j/  -  ^  \  r.„^A^^l;rj^  Branch. 


Space  marked  X  was 
or/^inal/y  on/y  wafer. 
Disfance  y-y  =  45  feet 


We  have  akeady  mentioned  the  fact  that  a  small  stream,  known  as 
Cave  Spring"  Branch,  drained  a  large  part  of  the  territory  covered  by 
the  encampments.  This  stream  empties  into  Chickamauga  Creek, 
and  the  intake  of  the  general  water  supply  was  located  dangerously 
near  the  junction  of  these  streams.  In  fact,  the  intake  of  the  water 
supply  was  immediately  at  the  junction  of  the  two  streams.  How- 
ever, Cave  Spring  Branch  was  deflected  from  its  course  by  a  canal 
and  dam,  so  that  it  emptied  into  Chickamauga  Creek  about  45  fset 
below  the  mouth  of  the  intake  iDipes.  The  first  attempt  to  deflect 
Cave  Spring  Branch  consisted  of  a  flimsy  riprap  wall,  consisting  of 
brush  and  broken  stones.  This  poorly  constructed  dike  was  washed 
away  by  the  first  hea\^  rain,  and  Cave  Spring  Branch  resumed  its 
original  course  and  flowed  into  Chickamauga  Creek  directly  around 
the  mouth  of  the  three  intake  pipes.  There  cei^tainly  was  no  ade- 
quate excuse  for  taking  the  water  from  this  point,  and  there  can  be 
but  little  doubt  that  the  water  supplied  through  the  pipes  did  on 
more  than  one  occasion  become  contaminated  with  the  drainage  from 
the  camps  flowing  into  Chickamauga  Creek  through  Cave  Spring 
Branch.  ^Yith  typhoid  fever  generally  distributed  through  the  regi- 
ments, the  infection,  as  we  have  already  seen,  being  brought  to  the 
park  by  most  of  the  regiments,  and  with  the  drainage  from  all  of  these 
camps  swept  into  this  stream,  it  is  impossible  that  the  water  of  Cave 
Spring  Branch  should  have  escaped  siDecific  contamination  with  the 
typhoid  bacillus,  and  it  is  well-nigh  impossible  that  the  water  of 
Chickamauga  Creek,  pumped  through  the  pipes  and  distributed 
through  the  camj)s,  altogether  escaped  this  contamination.  In  our 
opinion,  there  is  but  little  doubt  that  the  general  water  supply  at 
Chickamauga  became  slightly  contaminated.  However,  we  are  con- 
vinced from  the  distribution  of  the  disease  through  the  different 
organizations  that  contamination  of  the  water  supply  was  only  one  of 


40 

the  means  through  which  the  disease  was  spread.  Moreover,  as  we 
have  already  seen,  the  Second  Division  of  the  First  Army  Corps  was 
quite  removed  in  its  location  from  the  water  mains  and  pipes,  and  the 
men  of  this  division  could  only  occasionally  reach  this  water,  and  yet 
this  division  suffered  like  the  others  from  typhoid  fever.  For  these 
and  other  reasons  that  have  already  been  given,  we  are  inclined  to 
think  that  infected  water  was  not  the  chief  source  of  the  spread  of 
typhoid  fever  among  the  troops  encamped  at  Chickamauga. 

Unfortunately  no  satisfactory  bacteriological  examination  of  any 
of  the  waters  used  by  the  troops  at  Chickamauga  was  made  at  the 
proper  time.  On  August  5,  1898,  Professor  Slocum,  of  Knoxville, 
Tenn. ,  made  a  chemical  analysis  of  forty-three  samples  of  water  taken 
from  various  sources  in  the  x)ark.  This  analysis  consisted  of  a  deter- 
mination of  the  amount  of  oxygen  consumed.  While  we  do  not  place 
an}^  stress  upon  the  value  of  these  analyses,  inasmuch  as  the  evidence 
furnished  is  not  convincing,  we  think  ourselves  justified  in  presenting 
in  the  followins;  tabular  form  the  results  of  Professor  Slocum's  work: 


Besults  of  analysis  of  icater  from  various  sources  used  by  the  troops  in  Camp 
George  H.  Thomas,  Chickamauga  Park,  Georgia,  August  5,  1898. 


No. 


Source. 


Location. 


Oxygen 

^?.'^La   'Quality of 
sumed   i  ^       ^. -L 
in  100,000      water, 
parts. 


Remarks. 


16 


Well.. 

Spring 
Well  . . 

....do.- 


Spring . 
Well  .  - 
Spring 

....do... 

--.-do... 
10     Well... 


.--.lO.. 

Spring 
Well  . . 
....do-. 

.---do.. 


...do.. 


ir 

-...do..- 

18 

....do... 

19 

-...do... 

20 
21 

....do... 
....do... 

22 

....do... 

23 

24 

....do... 
Spring . 

2.5 

Well.  - 

26 

....do... 

Brotherton  road  at  Howell's 
battery. 

Jay's  mill 

Alexander  road  at  Tom  Little's, 
12tli  Minnesota. 

Viniard-Alesander  road,  Wal- 
thall's shop. 

Mullis,  north  end  of  park 

Dyer  House  yard 

i  Blue,  over  Chickamauga  Creek.. 

Ellis,  on  Ringgold  road 

Cloud,  on  Lafayette  road--- 

Reed's,  Brotherton  road,  south- 
west of  Brannans,  160th  In- 
diana. 

Dyer  House,  westof.  near  spring. 

Dyer's,  west  of  house 

Wood's  yard 

Brotherton  road,  at  old  county 
road. 

Brotherton    road     a 
headquarters. 


Lafayette  road,  south  of  Saw- 
mill Fork. 

Brotherton  road  at  Jay's  Mill 
junction. 

Viniard  House  yard 


Reed's.  Brotherton  road,  west  of 
2d  Minnesota  monument. 

Brotherton  House 

Lafayette  road,  250  yards  south 
of  iSrotherton's. 

Jay's  mill  road,  north  of  Alex- 
ander road. 

Bagwell's  store 

White  Smith's,  near  ravine 


Brannan's  house  yard  (old  well) . 
Brannan's  front  yard 


0.26     Impure 
.09     Pure 


.06 


-do.. 
...do.. 


...-do.... 
..-.do.... 
....do...- 
-..-do-... 
...do---. 
....do-... 


do.. 

Impure 
Pure  ... 

do-. 


Doubtful 
purity. 


Pure 

do... 


Med  i  u  m 

purity 

Impure  . . 

Pure    

do.... 

do.... 


do---. 

Doubtful 

purity. 

do.... 

do.... 


Cased  well,  not  used. 

Cased  well. 
Do. 

Do. 
Do.  • 


Do. 

Stock  only. 

Cased  well. 

Do. 

Cased  well.  Use  stopjjed, 
but  declared  good  after 
analysis  by  Philadelphia 
board  of  health  or  wa- 
ter board. 

Cased  well. 

Do. 

Open  dug  well. 

Cased  well. 

Do. 
Do. 

Do. 

Open  dug  well. 

Shallow   dug   well.      Use 

stopped  early. 
Shallow    dug  well.    Used 

by  troops. 
Cased  well,  finished  among 

last. 


41 


Results  of  analysis  of  loater  from  various  sources,  etc. — Continued. 


No.    Source. 

Location. 

Oxygen 

con- 
sumed 

in  100,000 
parts. 

Quality  of 

water. 

Remarks. 

97 

Well  ... 
....do... 

Spring  - 

Well... 

....do... 

.-.do--. 
....do... 

Spring  - 
Well  ... 

...do... 
....do... 

....do... 

Pipe 

line. 
Well  ... 

...-do.-- 
....do... 
Spring . 

0.07 
.01 

.20 

.06 

Pure 

do.... 

Doubtful 
purity. 
Pure 

Sample 
broken. 

Pure 

do--.. 

do..- 

do  .... 

do.... 

do..-- 

do---. 

Medium 
■    purity. 

Doubtful 
purity. 

Pure 

do-.. 

do.... 

Shallow  dug  well. 
Cased  well. 

Deep  spring.    Use  stopped 

early. 
Cased  well. 

Do. 

28 

Alexander  Bridge  road,  between 
Winfrey's  and  Benton's. 

30 
31 

Poe  field,  northeast  of  Georgia 

monument. 
Poe  field,  east  of  Georgia  mon- 
ument. 

Lafayette  road,  Kelly  house 

Glenn-Kelly    and    Baird    road. 

Dyer  field 

32 
33 

34 

.06 
.03 

.09 
.03 

.10 
.10 

.10 

.03 

.15 

.03 
.42 
.10 

Do. 
Do. 

Bold,  shallow  spring. 
Cased  well. 

Do. 
Do. 

Do. 

Pipe     line,    Chickamauga 

Creek. 
Cased  well,  not  used. 

Cased  well. 

Do. 
Large,   shallow,     open 
spring. 

35 

36 
37 

38 

3P 

Lafayette  road,  north  of  Kelly 

house. 
Lafayette  and  Alexander  roads. 
Lafayette   and    Reeds    Bridge 

roads. 
Glenn-Kelly      and     Snodgrass 

roads. 

40 

41 
42 
43 

Rostrum,  foot  of  Snodgrass  HilL 

Vittetoe  roads,  near  Vittetoes  .. 
Lytle  Hill,  on  Glenn-Kelly  road.. 
Scott's,  south  of  Viniard's 

Classification  of  FranMand  and  Tidy. 

Oxygen  consumed  in  100.000  parts  of  water. 
Section  1. — Upland  surface  water — 

Class  1. — Water,  great  organic  purity  not  naore  than 0.1 

2. — Water,  medium  purity  not  more  than .21 

3. — Water,  doubtful  purity  not  more  than ._ 4 

4. — Wa  er,  impure  more  than. .4 

Section  2. — Deep  wells  and  springs — 

Class  1. — Water,  great  organic  purity  not  more  than _.     .055 

2. — Water,  medium  purity  not  more  than.   .15 

3. — Water,  doubtful  purity  not  more  than .2 

4. — Water,  impure  more  than 3 

In  September,  1898,  Acting  Assistant  Surgeon  Carroll,  under  the 
direction  of  our  board,  collected  samples  of  water  from  various 
sources  in  Chickamauga  Park  and  submitted  the  same  to  bacteriolog- 
ical examination.  Of  course  we  understand  that  the  bacterial  flora 
of  these  waters  in  September  does  not  represent  the  condition  of  the 
same  waters  in  August.  However,  we  had  the  waters  examined  as 
soon  as  we  were  able  to  do  so.  We  publish  in  the  attached  tables 
the  results  of  Dr.  Carroll's  work.  It  will  be  seen  that  he  found  the 
bacillus  pyocyaneus  in  many  of  these  waters.  We  do  not  know 
that  ^xij  importance  whatever  is  to  be  attached  to  the  Avide  distribu- 
tion of  this  bacillus  in  the  waters  of  Chickamauga  Park,  nor  shall  we 
attempt  to  draw  any  conclusions  therefrom.  This  organism  has  been 
found  occasionally  in  the  drinking  water  supplied  to  various  cities. 
We  give  the  results  of  Dr.  Carroll's  work  without  further  comment. 


42 

Results  obtained  with  water  from  Camp  George  H.  Thomas,  Chickamauga  Parle, 
Georgia,  collected- September  27,  1898. 


Location  of  well  or  spring. 


4-day  culture  at  39°  to  41° 


Guinea 

pig. 
weight. 


Died. 


At  foot  of  Lytle  Hill  headquarters  . . . 

Headquarters  well,  outside.- _ 

Dyer  House  spring,  open  lor  stock. _. 

Well  yard  at  park  headquarters 

Wood's  well  at  park  headquarters 

Dyer  field  spring 

Well  at  junction  of  Bayard  and  Kelly 
roads. 

At  Snodgrass  crossroads 

Well  at  west  fork  of  Glenn-Kelly  road. 
north  of  Snodgrass  crossroads. 

First  well  south  of  stone  crusher, 
Glenn-Kelly  road,  west  fork. 

Mullis  spriijg  .__ 

McDonald  well. _ 

Cloud  .spring,  said  to  be  responsible 
for  a  number  of  cases,  open,  water 
dipped. 

Ale.xander  well,  Alexander  and  La- 
fayette roads. 

Glenn  Kelly  road,  west  of  Kelly  field. 

Kelly  field  well,  Lafayette  road 

Kelly  House  well 

Well  east  of  m^rth  end  of  Poe  field  . . . 

Shallow  well  in  hard  rock,  east  of  Poe 
field,  opposite  Georgia  State  inonn.- 
ment. 

Brotherton  well,  on  Lafayette  road . . 

On  Lafayette  road,  south  of  Brother- 
ton's,  near  Humphries'  Arkansas 
Battery. 

Means  spring,  open,  water  dipped 

Well  on  Lafayette  road,  south  of  saw- 
mill fork  of  Glenn-Kelly  rf)ad. 

Viniard- Alexander  road  at  Blacker's 
house. 

Scott  spring,  open,  dipped 

Chickamauga  Creek,  one-fourth  mile 
above  intake. 

Chickamauga  Creek  at  intake 

Cave  Spring  Branch 

Well  on  N'iniard-Alexander  road,  300 
yards  east  of  road  to  Hall's  tower. 

Well  on  Alexander  road,  north  of 
Alexander  house  2.o0  yards. 

Well  on  Viniard- Alexander  road,  at 
old  blacksmith  shop  of  Walthall. 

Well  on  Jay's  3iill  road,  100  yards 
north  of  Alexander  junction. 

Well  on  Alexander  Bridge  road,  at 
Osborne's  house. 

Well  on  the  old  Alexander  (county) 
road,  halfway  between  Brotherton 
and  .Jay's  Mill  roads. 

Well  on  Alexander  road,  between  the 
Winfrey  and  O.sborne  houses. 

Well  on  Brotherton  road,  at  junction 
of  old  Alexander  (county) road. 

Well  on  Brotherton  road,  at  Howell's 
battery:  bottle  lowered  with  string. 

Well  on  Brotherton  road,  at  Bragg's 
headquarters  monument. 

Well  on  Javs  Mill  road,  200  feet 
south  of  Brotherton  road. 

Jay's  Mill  spring ...- 

Well  on  Reed's  Bridge  road,  at  Bran- 
nan's  (Peter's)  house. 

Well  on  the  Jay's  Mill  branch,  400 
yards  west  of  Brannan's  house. 

Well  on  Reed's  Bridge  road,  halfway 
between  Second  Minnesota  monu- 
ment and  the  road  from  the  tower. 

Crawfish  Spring,  at  Leiter  Hospital, 
outside. 

Crawfish  Spring  water,  from  Leiter 
Hospital  faucet. 


Plain  bouillon  ,1  c.  c. 

do-_._ _.. 

do 

do. 

do... 

do 

do 


.do. 
.do. 

do. 

.do. 
.do. 
.do. 


.do. 

.do. 
.do. 
.do. 
.do_ 
.do. 


.do. 
.do. 


.do. 
.do. 

.do. 

.do. 
.do. 

.do. 
.do. 
.do. 

.do. 

.do. 

.do. 

.do. 

.do. 

.do. 

.do. 

.do. 

.do. 

,do. 

.do. 
.do. 

.do. 

.do. 

.do. 
.do. 


Grams. 
3.50 
460 
425 
365 
470 
415 
4.50 

420 
585 

430 

725 
340 
305 


345 


17  hours. 

18  hours. 
17  hours. 

Do. 

Do. 
25  hours. 
17  hours. 

Do. 
Do. 

Do. 

Do. 

Do. 

Do. 


320 
520 
570 
415 
360 

Do. 
Do. 

24  hours 
17  hours 
Do. 

345 
495 

Do. 
Do 

660 
320 

25  hours 
17  hours 

355 

Do. 

325 

575 

Do. 
11  days. 

615 
615 
335 

17  hours. 
11  days. 
34  hours 

625 

Do. 

355 

17  hours 

•     370 

41  hours 

390 

11  days. 

395 

21  days. 

350 

34  hours 

755 

17  hours 

420 

23  hours 

495 

30  hours. 

435 

17  hours. 

345 

545 

Do. 
Do. 

415 

Do. 

340 

Do. 

370 

Do. 

Notnoted. 

23  hours. 

43 


Results  obtained  loith  water  from  Camp  George  H.  Thomas,  etc. — Continued. 


No. 

Location  of  well  or  spring. 

5-day  cul- 
ture at  39° 
to  41°  C. 

Guinea 

pig, 
weight. 

Died. 

Organism  obtained. 

1 

At  foot  of  Lytle  Hill  headquarters... 

Gas  tube, 

0.3  c.  c. 
do 

Grams. 

227 

240 
240 

227 

232 

240 
250 

250 
250 

275 

245 
355 
270 

300 

320 
275 
270 
310 

210 

645 
535 

310 
415 

380 

250 

275 

395 
245 
235 

740 

313 

550 

565 

610 

485 
515 
545 
300 
345 

355 

305 

265 

Pyocyaueus,  first  pig. 

f. 

10  days. 

3 

do 

Do. 

4 

do 

17  hours 

Pyooyaneus,  first  and 

second  pigs. 
Pyocyaneus, first  pig. 

5 

Wood's  well  at  park  headquarters  . 

do 

fi 

Dyer  fleld'sprin'g                 

do 

11  days  . 
....do... 

7 
8 

Well  at  junction  of  Bayard  and  Kelly 
roads. 

do 

.  do   . 

Do. 
Do 

q 

Well  at  west  fork   of  Glenn-Kelly 
road,  north  of  Snodgrass  cross  roads 

Fir.st  well  south  of  stone  crusher, 
Glenn-Kelly  road,  west  fork. 

do. 

do 

do 

Do. 

10 

n 

14  hours 

Pyocyaneus,    second 
Pyocyaneus,  first  pig. 

T^ 

McDonald  well 

...  do   ..  . 

10  days  - 
22 hours 

14  hours 

...do... 

12 hours 

15  hours 
24  hours 

10  days 

32hojirs 
17houri-. 

13 

14 

15 

16 

Cloud  spring,  said  to  be  responsible 
for  a  number  of  cases,  open,  water 
dipped. 

Alexander  well,  Alexander  and  La- 
fayette roads. 

Glenn-Kelly  road,  west  of  Kelly  field. 

do 

do.... 

do 

do 

Pyocyaneus,        both 
pigs. 

Pyocyaneus,    second 

^%o. 
Pyocyaneus,  first  pig. 

17 

do 

18 

Well  east  of  north  end  of  Poe  field. .. 

do 

Pyocyaneus,        both 

19 
^(1 

Shallow  well  in  hard  rock,  east  of  Poe 
field,  opposite  Georgia  State  monu- 
ment. 

do 

do   .... 

pigs. 
Pyocyaneus,  first  pig. 

Pyocyaneus,        both 

pigs. 
Pyocyaneus,first  pig; 

21 

On  Lafayette  road,  south  of  Brother- 
ton's,  near  Humphries'  Arkansas 
Battery. 

do..... 

...  do 

^3 

Well  on  Layfayette  road,  south  of 
sawmill,  tork  of  Glenn- Kelly  road. 

Viniard- Alexander  road  at  Blacke's 
house. 

do   .... 

do 

do 

Do. 

24 

23  hours 
6  hours. 

19  days. 
10  days . 

20  days . 

Pyocyaneus,        both 
pigs. 
Do. 

26 

''7 

Chickam'auga  Creek,  one-fourth  mile 
above  intake. 

do 

...  do. 

Pyocyaneus,  first  pig. 

98 

( 'a ve  Spring  Branch      

....  do 

29 
30 

Well  on  Viniard-Alexander  road,  300 

yards  east  of  road  to  Hall's  tower. 
Well  on  Alexander   road,  north  of 

Alexander  house  250  yards.. 
Well  on  Viniard-Alexander  road,  at 

old  blacksmith  shop  of  Walthall. 
Well  on  Jay's  Mill  road,  100  yards 

north  of  Alexander  Junction. 
Well  on  Alexander  Bridge  road,  at 

Osborne's  house. 
Well  on  the  old  Alexander  (county) 

road,  halfway  between  Brotherton 

and  Jay's  Mill  r.  ads. 
Well  on  Alexander  road,   between 

the  Winfrey  and  Osborne  houses. 
Well  on  Brotherton  road,  at  junction 

of  old  Alexander  (county)  road. 
Well  on  Brotherton  road,  at  Howell's 

battery;  bottle  lowered  withstring. 
Well  on 'brotherton  road,  at  Bragg's 
headquarters  monument. 
Well  on    Jay's    Mill    road,  200  feet 

south  of  Brotherton  road. 

do 

do 

do 

do 

do 

do 

dO-.-^. 

do..-. 

do 

do 

do 

do 

31 

9  days.- 

Do. 
Do. 

S3 

3-1 

35 

Do. 

36 
37 
38 
39 
-10 

5  days . . 
34  hours 
22  hours 
20  days . 

Do. 

Pyocyaneus,    second 
pig- 

41 

42 

Well  on  Reed's  Bridge  road,  at  Bran- 
nan's  (Peter's)  house. 

Well  on   the  Jay's  Mill   branch,  400 
yards  west  of  Brannan's  house. 

Well  on  Reed's  Bridge  road,  halfway 
between  Second  Minnesota  monu- 
ment and  the  road  from  the  tower. 

Crawfish  Spring,  at  Leiter  Hospital, 
outside. 

Crawfish  Spring  water,  from  Leiter 
Hospital  faucet. 

do 

do 

do' 

Pyocyaneus,first  pig. 
Do. 

43 

Do. 

44 

doi 

• 
Do. 

45 

doi 

Do. 

'  Tubes  exhausted. 


44 

Results  obtained  loith  water  from  Camp  George  H.  Thomas,  etc. — Continued. 


No. 


Location  of  well  or  spring. 


Fermentation  test. 


Condition  of  water. 


1  At  foot  of  Lytle  Hill  headquarters 

2  Headquarters  well,  outside 

3  Dyer  house  spring,  open  for  stock 

4  Well  yard  at  park  headquarters  . 
Wood's  well  at  park  headquar- 
ters. 

6  Dyer  field  spring    

7  Well  at  .1  unction  of  Bayard  and 
Kelly  roads. 

At  Sundgrass  crossroads 

Well  at  west  fork  of  Glenn-Kelly 
road,  north  of  Snodgrass  cross- 
roads. 

10  First  well  south  of  stone  crusher, 
I      G-lenu-Kelly  road,  west  fork. 

11  '  Mullis  spring.  __ 

12  McDonald  well ._ 

13  Cloud  spring,  said  to  be  responsi- 

ble for  a  number  of  cases,  open, 
water  dipped. 

14  Alexander  well,  Alexander  and 

Lafayette  roads. 

15  Glenn-Kelly  road,  west  of  Kelly 

field. 

16  Kelly  fiela  well,  Lafayette  road.. 

17  Kelly  house  well  . .  _ _ 

18  Well  east  of  north  end  of  Poe  field 

19  Shallow  well  in  hard  rock,  east 

of  Poe  field,  opposite  Georgia 
State  monument. 

20  Brotherton  well,  on  Lafayette 
I      road. 

21  On    Lafayette    road,    south    of 

Brotherton's,  near  Humphries' 
Arkansas  Battery. 

22  Means  spring,  open,  water  dipped 

23  Well  on  Lafayette  road,  south  of 

sawmill,  fork  of  Glenn-Kelly 
road. 

24  Viniard-AlexanderroadatBlack- 
!      er's  house. 

25  Scott  spriDg,  open,  dipped 

26  Chickamauga  Creek,  one-fourth 
!      mile  above  intake. 

27  Chickamauga  Creek  at  intake 

28  Cave  Spring  Branch 

29  Welt  on  Viniard- Alexander  road, 

30iJ  yards  east  of  road  to  Hall's 
tower. 

30  Wellon  Alexander  road,  north  of 

Alexander  house  2.50  yards. 

31  Well  on  Viniard- Alexander  road, 
1  at  old  blacksmith  shop  of  Wal- 
I      than. 

32  Well  on  .j  ay's  Mill  road.  100  yards 

north  of  Alexander  .Junction. 

33  Well  on  Alexander  Bridge  road, 

at  Osborne's  house. 

34  Well     on     the     old    Alexander 

(county)  road,  halfway  be- 
tween Brotherton  and  Jay's 
Mill  roads. 

35  Wellon  Alexander  road,  between 

the  Winfrey  and  Osborne 
houses. 

36  Well  on  Brotherton  road,  at  junc- 

tion of  old  Alexander  (county) 
road. 

37  Well  on  Brotherton  road .  at  Ho w- 

ell's  battery;    bottle  lowered 
I      with  string. 

38  I  Well    on    Brotherton    road,    at 

Bragg's    headquarters   monu- 
i      ment. 


Lactose 

Saccharose 

Glucose 

Lactose 

Glucose 

Saccharose 
Glucose 

Lactose 

Glucose 


Lactose 


do 

Saccharose. 
Lactose 


Glucose 

do 

Saccharose 

do 

Lactose  

do 

Saccharose. 
Glucose  


Saccharo.se. 
Glucose 


-do 


Lactose 

do 

Saccharose. 

do 

do 


do 

Lactose 

Glucose 

do 

do 


do 

Saccharose. 

Lactose 

Saccharose. 


Cm. 
6.0 
6.2 
.5.5 
.6 
4.2 

4.6 
2.5 

3.0 
0 


4.8 
L2 
6:5 


5.0 

1.2 

0 
0 

1.3 
1.5 

0 

2.7 


5.0 
4.3 


4.2 

5.0 
6.0 

6.0 
3.6 

0 


2.1 
0 

3.3 

0 
.6 

0 
0 

2.0 
0 


Cm. 

6.8 
12.0 
7.6 
2.0 
5.3 

7.5 
6.1 


5.5 
2.0 


1.5 

0 

5.0 

4.8 


0 

8.5 


10.6 
Max. 


5.6 
6.6 


6.0 

0 

4.0 

0 

3.0 

0 
0 

6.6 
0 


Cm. 
Max 

12.4 

Max. 

2.2 

Max 

8.0 
6.6 


Cm. 


Max 


Max 
Max. 


4.8    Max 
0  0 


Max, 

Max. 

3.2 

Max 


3.5 


11.5  :  11.6 

4. 5  !  Max 


Max 


Max. 
0 

6.1 
6.4 


0 
9.5 


0 
Max, 
Max, 


0 
Max, 


9.0  I  10.1 


Max. 


Max. 
Max. 


9.6  :Max. 
7.8  Max. 
2.0      2. 3 


2.5 


Max. 
0 

Max. 
0 
3.4 

0 

0 

10.3 

0 


0 
Max. 

0 

0 

Max. 

0 


Clouded. 
Clear. 

Do. 

Do. 

Do. 

Quite  cloudy. 
Do. 

Clear. 
Do. 


Do. 

Slightly  opalescent 
Clear. 
Do. 


Very  cloudy. 

Clouded. . 

Very  cloudy. 
Opaque  yellowish. 
Quite  clouded. 
Pale  brownish  yel- 
low in  color. 

Clear. 

Opaque  dirty 
brownish  yellow 
in  color. 

Clear. 

Clouded,  dirty 
looking. 

Clear. 

Slightly  opalescent. 
Clouded. 

Do. 
Slightly  cloudy. 
Clear. 


Quite  cloudy. 
Clouded. 

Clear. 

Do. 
Slightly  clouded. 

Do. 
Clear. 


Quite     clouded; 
murky. 

Clear. 


45 


Results  obtained  loith  loater-  from  Camp  George  H.  Thomas,  etc. — Continued. 


Location  of  well  or  spring. 

Fermentation  test. 

No. 

i 

3 

m 

>> 

>> 

a 
o 
o 

>, 

XI 

o 

Condition  of  water. 

39 

40 
41 
43 

43 

Well  on  Jay's  Mill  road,  200  feet 

south  of  Brotherton  road. 
Jay's  Mill  spring 

Well  on  Reed's  Bridge  road, 
at  Brannan"s  (Peter's  i  house. 

Weil  on  the  Jay's  Mill  branch, 
400  yards  west  of  Brannan's 
house. 

Well  on  Reed's  Bridge  road,  half- 
waj-  between  Second  Minne- 
sota monument  and  the  road 
from  the  tower. 

Crawfish  Spring,  at  Leiter  Hos- 
pital, outside. 

Crawfish  Spriug  water,  from  Lei- 
ter Hospital  faucet. 

Glucose  

Lactose 

Glucose 

do 

Cm. 
3.4 

3.  .5 

3.8 

3.0 

Cm. 
4.6 

10.0 

6.5 

r..5 

Cm. 
9.0 

n.o 

Max. 

8.3 

Cm. 
Max. 

Max. 
Max. 

Opaque;  very 
cloudy. 

Clouded;  rust  col- 
ored. 

Clear. 

Clouded. 

Opaque;  dirty  look- 
ing. 

Clear. 

44 

4,5 

Do. 

Acting  Asst.  Surg.  Charles  F.  Craig  in  his  report  from  the  bacteri- 
ological laboratory  of  Sternberg  Hospital,  to  be  appended  later,  gives 
some  information  concerning  the  bacteriology  of  some  of  the  waters 
in  the  park.  However,  as  his  report  refers  chieflj'  to  the  existence  of 
malaria,  we  will  give  the  results  of  his  work  under  that  head. 

In  order  to  show  that  many  of  the  medical  oflBcers  at  Chickamauga 
Park  realized  the  gravity  of  the  situation  early  in  the  season,  we  give 
from  the  large  list  of  papers  in  our  possession  the  following : 

Headquarters  First  Brigade, 

Third  Division,  First  Army  Corps, 
Camp  George  H.  Thomas,  Chickamauga,  (^t. ,  June  27,  1898. 
Sir:  O'wing  to  the  amount  of  diarrheal  trouble  and  the  increase  of  typhoid  and 
other  fevers  in  this  brigade,  I  have  the  honor  to  recommend  that  the  command  be 
required  to  use  only  boiled  water  for  drinking  purposes.  The  i^resent  directions 
for  boiling  water  are  not  carried  out.  This  is  partly  due  to  the  want  of  i^roper 
utensils  and  facilities  for  storing  water.  I  would  recommend  that  ordinary  wash 
boilers  be  obtained  for  boiling  the  water,  and  the  proper  number  oi:  barrels  for 
storing  and  cooling  it  be  jprocured,  but  that  the  command  be  required  to  utilize 
such  things  as  they  may  have  until  the  desired  equipment  has  been  obtained. 

As  the  rear  sinks  are  infected  by  the  excreta  of  patients  with  typhoid  fever,  I 
would  recommend  that  chloride  of  lime  be  obtained  in  large  quantities  for  their 
disinfection,  and  that  every  man  using  the  sinks  be  required  to  use  earth,  or  a 
mixture  of  earth  and  lime,  at  once,  so  that  at  no  time  will  excreta  be  exposed  to 
the  air  and  flies. 

As  this  is  a  very  important  matter,  I  would  recommend  that  urgent  measures 
be  taken  to  procure  the  boilers,  barrels,  and  lime  at  once,  without  regard  t  j  the 
ordinary  methods  of  business. 

I  remain,  very  respectfully,  J.  D.  Glennan, 

Major  and  Surgeon,  V.  S.  V.,  Brigade  Surgeon. 
The  Assistant  Adjutant-General, 

First  Brigade,  Third  Division,  First  Army  Corps. 


46 

Sin'ks. — The  difficulty  that  was  experienced  in  digging  sinks  of 
proper  depth  has  alreadj^  been  frequently  referred  to.  The  rocky 
nature  of  the  soil  in  many  places  made  it  well  nigh  impossible  to  pro- 
vide sinks  of  proper  dimensions.  When  rock  has  to  be  blasted  in 
order  to  prepare  a  sink,  the  result  must  always  be  more  or  less  unsat- 
isfactory. However,  the  diffieultj^  in  providing  and  caring  for  the 
sinks  was  not  confined  to  their  construction.  The  amount  of  dirt 
thrown  out  in  the  digging  of  these  sinks  was  inconsiderable,  and  after 
It  had  been  on  the  surface  in  the  sun  it  became  almost  as  hard  and 
nonporous  as  rock.  When  this  dirt  was  thrown  back  into  the  sink,  it . 
did  not  absorb  the  liquid  contents,  but  simplj^  displaced  the  watery 
material,  and  when  thrown  in  in  considerable  quantities  caused  the 
sinks  to  overflow.  There  was  an  almost  universal  complaint  from 
regimental  medical  officers  that  lime  could  not  be  obtained  early  in  the 
season  for  the  disinfection  of  sinks.  It  seems  strange  that  no  one 
apparentl}^  ever  thought  of  the  possibility  of  manufacturing  enough 
lime  to  supply  the  entire  encampment.  There  is  in  the  park  practi- 
cally an  unlimited  supply  of  wood,  and  certainly  an  unlimited  supply 
of  limestone  rock.  The  construction  of  a  few  limekilns  would  not  have 
been  a  herculean  task  with  the  large  number  of  men  on  hand,  and  this 
might  have  supplied  an  abundance  of  lime.  However,  we  are  satisfied 
that  if  there  had  been  no  shortage  in  lime  the  condition  of  affairs  would 
not  have  been  greatly  improved.  The  thorough  disinfection  of  the 
excretions  of  60,000  men,  when  deposited  in  pits  in  the  earth,  and 
especially  when  scattered  on  the  surface  of  the  earth,  is  not  an,  easy 
task.  We  may  regard  it  as  an  axiom  that  wherever  and  whenever  a 
large  number  of  men  assemble  and  allow  their  own  excretions  to  accu- 
mulate about  them,  there  and  then  typhoid  fever  will  appear  and  will 
spread. 

We  do  not  mean  to  imply  by  this  that  typhoid  fever  ever  origi- 
nates de  novo,  nor  do  we  mean  to  have  anyone  understand  that  we 
believe  that  the  colon  bacillus,  or  any  other  germ  present  in  the 
normal  excretions  of  men,  can  develop  into  the  typhoid  bacillus. 
We  do  mean  that  tj^phoid  fever  is  so  widely  distributed  that  in  any 
large  assembly  of  men  collected  from  different  parts  of  the  country 
there  will  be  some  already  infected  with  typhoid  fever.  From  the 
dejections  of  these  the  typhoid  bacillus  will  grow  and  flourish  in 
polluted  places,  and  the  disease  will  develop  and  spread.  If  the 
troops  at  Chickamauga  had  been  provided  with  ample  means  for  dis- 
infecting all  excretions,  we  do  not  suppose  that  even  under  these  con- 
ditions typhoid  fever  would  have  been  altogether  unknown,  but  the 
disease  might  have  been  limited  to  the  men  who  reached  the  camp 
infected  and  there  could  have  been  no  widespread  epidemic.  We 
are  quite  thoroughly  convinced  that  some  substitute  must  be  provided 
for  the  pit  system  in  permanent  camps.  While  troops  are  on  the 
march,  stopping  here  and  there  for  a  day  or  two  at  most,  pits  for  the 
disposition  of  fecal  matter  are  sufficient,  but  in  permanent  camps 


47 

they  always  have  been,  are,  and  probably  always  will  be,  a  menace 
to  the  health  of  any  command.  While  it  is  trne  that  it  was  well  nigh 
impossible  to  properly  construct  sinks  at  Chickamauga,  it  must  not  be 
forgotten  that  in  other  encampments  where  there  was  no  difficulty  in 
digging  sinks  and  where  there  was  no  scarcity  of  earth  suitable  for 
covering  their  contents  typoid  fever  prevailed  extensively.  It  has 
b^en  urged  by  some  that  the  great  prevalence  of  typhoid  fever  at 
Chickamauga  was  due  to  the  fact  that  such  large  numbers  of  troops 
were  massed  at  one  place.  Relatively  there  is  some  truth  in  this,  but 
at  no  time  was  the  density  of  the  soldier  population  of  Chickamauga 
Park  as  great  as  that  of  many  of  our  cities  in  which  typhoid  is  a  rare 
disease.  It  can  not,  therefore,  be  truly  said  that  typhoid  fever  at 
Chickamauga  was  the  result  of  the  massing  of  a  large  number  of  men. 
At  least  the  spread  of  the  disease  was  only  incidental  to  this.  If  the 
excretions  of  these  men  could  have  been  carried  away  by  means  of 
properly  constructed  sewers,  or  if  they  could  have  been  disinfected, 
and  if  camp  pollution  had  not  been  permitted,  and  if  a  pure  water  sup- 
ply had  been  obtained,  there  is  no  reason  why  typhoid  fever  should 
have  been  more  prevalent  among  the  troops  at  Chickamauga  in  the 
summer  of  1898  than  it  was  in  New  York  City. 

We  repeat  that,  in  our  opinion,  the  sink  must  no  longer  be  per- 
mitted in  permanent  encampments.  When  possible,  water  carriage 
for  fecal  matter  may  be  adopted,  and  when  this  is  impracticable  the 
thorough  disinfection  of  all  fecal  matter  in  tubs  as  recommended 
b}^  this  board  will,  we  believe,  reduce  typhoid  fever  in  permanent 
encampments  to  a  few  sporadic  cases. 

Camp  pollution. — The  greatest  sanitary  sin  committed  among  the 
troops  at  Chickamauga  in  1898,  as  well  as  in  most  other  national 
encampments,  was  that  of  camp  pollution.  Some  of  the  regimental 
camp  sites  became  most  disgustingly  filthy.  It  is  unnecessary  to 
rei)eat  our  evidence  on  this  point.  Reference  to  the  regimental  his- 
tories already  recorded  will  give  one  some  idea  of  the  condition  of 
some  of  these  camps.  A  few  extracts  from  our  stenographic  notes, 
taken  at  the  time  of  our  inspection,  further  illustrate  this  point: 

In  the  camp  of  the  Third  U.  S.  Volunteer  Cavalry  we  found  the  sinks  full  to 
the  top  wiih  fecal  matter;  soiled  paper  was  scattered  about  the  sinks,  and  the 
woods  behind  the  reg  mental  camp  was  strewn  with  fecal  matter.  The  Second 
Kentucky  Volunteer  Infantry  was  located  in  the  woods;  fecal  matter  was  depos- 
ited around  trees,  and  ilies  swarmed  over  these  deposits  not  more  than  150  feet 
from  the  company  mess  tents;  the  odor  in  the  woods  just  outside  of  the  regimen- 
ta.  liLes  was  vile.  In  the  Ninth  New  York  we  found  three  battalion  sinks  sup- 
posed to  have  been  filled  with  straw  and  burned  out  that  morning.  Fecal  matter 
was  found  deposited  on  the  ground  around  trees,  and  a  vile  odor  permeated  the 
air  about  the  sinks. 

We  found  in  the  hospital  of  the  Third  Division  of  the  First  Army 
Corps  that  the  stools  were  not  disinfected  at  all.  The  bedpans  were 
washed  in  water  and  were  not  disinfected.  The  fecal  matter  of  attend- 
ants was  received  in  galvanized-iron  boxes,  of  very  imperfect  pattern. 


There  was  abundant  opportunity  for  the  outside  of  the  boxes  to 
become  foul,  and  there  was  no  means  provided  for  properly  han- 
dling these  boxes.  These  are  illustrations  of  the  condition  that  we 
found  at  Chickamauga.  When  our  board  visited  Chickamauga  most 
of  the  regiments  had  already  departed,  and  it  was  expected  that  only 
the  Sixth  U.  S.  Volunteer  Infantry  would  remain.  The  following  is  a 
copy  of  our  recommendations  to  General  Boj^nfcon  concerning  the  care 
that  should  be  practiced  b}^  this  regiment: 

Knoxville,  Tenn.,  September  14,  1898. 
GrENERAL:  The  board  of  medical  officers  convened  by  Special  Orders,  No.  194, 
paragraph  40,  Adjutant-Generars  Office,  Washington,  D.  C,  August  18,  1898,  for 
the  special  investigation  of  the  origin  and  spread  of  typhoid  fever  in  the  army 
camps,  begs  to  submit  the  following  recommendations  concerning  the  Sixth  U.  S. 
Volunteer  Infantry,  the  on'y  regiment  now  encamped  at  Chickamauga  Park: 

1.  Water  supply. — The  men  of  th!s  regiment,  being  supplied  with  a  presumably 
pxare  water  from  Mullis  Spring,  should  be  compeLed  to  use  this  water  only  and  no 
other  for  any  purpose  whatever.  Every  precaution  should  be  taken  to  see  that 
patrol  parties  should  be  supplied  with  drinking  water  from  this  source  whenever 
absent  from  camp  on  such  duty.  Suitable  bath  houses  should  be  erected  for  the 
use  of  the  men  and  they  should  be  compelled  to  use  this  water  for  bathing  pur- 
poses. Under  ho  circumstances  should  Chickamauga  Creek  water  or  water  from 
any  other  source  than  this  spring  be  used.  If  the  regiment  should  be  ordered  out 
for  a  march,  water  from  Mullis  Spring  in  abundant  quantity  should  be  carried 
along  for  drink. ng  purposes.  From  an  inspection  of  this  spring  and  its  immedi- 
ate surrounJ.ings  made  by  the  board,  we  recommend  that  immediate  measures  be 
taken  to  protect  the  spring  against  surface  drainage.  The  barrels  used  for  the 
purpose  of  storing  drinking  water  should  be  elevated  on  supports,  furnished  with 
stopcocks  for  withdrawing  the  Avater,  supplied  with  tight  covers,  and  protectedfrom 
the  sun  by  a  proper  shelter;  they  should  be  frequently  inspected  and  from  time  to 
time  cleansed  and  their  interiors  exposed  to  the  direct  sunlight  for  some  hours. 

2.  Mess  tents  and  kitchens. — No  measures  should  be  omitted  to  prevent  the 
access  of  flies  to  the  food.  The  board  therefore  urgently  recommends  that  both 
kitchens  and  mess  tents  should  be  promptly  and  thoroughly  screened.  All  milk 
consumed  should  be  boiled  and  thereafter  protected  from  the  flies  by  proper  screens. 
As  an  additional  precaution  the  cooks  and  attendants  about  the  kitchens  and  mess 
tents  should  be  compelled  to  thoroughly  and  frequently  wash  their  hands  with 
soap  and  water  every  time  they  go  to  the  kitchen  and  mess  tents  for  the  perform- 
ance of  their  duty.  None  but  authorized  persons  should  be  permitted  to  handle 
the  food  supplies.  Soldiers  should  be  forbidden  eating  any  fruit  or  drinking  any 
liquid  except  that  furnished  by  the  regiment.  Men  should  be  compelled  to 
thoroughly  wash  their  hands  before  going  to  meals. 

3.  Kitchen  garbage.— Suitable  vessels  should  be  provided  for  the  reception  of 
kitchen  garbage.  These  should  be  daily  removed  and  their  contents  buried  or 
burned  at  some  point  distant  from  the  camp;  for  the  garbage,  zinc  barrels  with 
proper  covers  are  recommended. 

4.  Company  sinks.— At  the  time  of  the  inspection  by  the  board  the  sinks  were 
in  foul  condition;  exposed  fecal  matter  was  found  in  every  sink.  The  board  can 
not  too  strongly  emphasize  the  necessity  of  each  individual  being  absolutely 
required  to  cover  his  own  excrement  with  dry  earth  before  leaving  the  sink,  and 
this  should  not  be  left  to  men  detailed  for  the  purpose,  as  with  details  fecal  mat- 
ter is  left  exp^osed  for  hours  to  the  access  of  flies.  The  sinks  should  be  sheltered, 
and  ditched  so  as  to  prevent  the  access  of  surface  water  to  them.  If  the  dry  earth 
closets  should  be  adopted  a  box  should  be  provided  separately  for  each  hole,  and 
should  be  wide  enough  to  receive  the  urine  and  fecal  matter  without  danger  of 


49 

these  being  deposited  outside  of  or  on  the  exterior  surfaces  of  boxes,  as  will  happen 
with  the  boxes  now  in  use  at  Sternberg  Hospital,  for  instance.  An  abundance  of 
well-dried  and  pulverized  earth  should  be  provided  in  storage,  completely  sheltered 
from  the  rain.  This  should  be  freely  used  in  the  bo::es,  each  man  being  compelled 
to  cover  his  excrement  as  in  case  of  the  sink.  In  addition  to  the  dry  earth,  lime 
should  be  used  at  least  once  a  day,  besides  always  being  freely  placed  in  the  boxes 
after  emptying  them.  In  order  to  insure  the  execution  of  this  measure,  if  neces- 
sary a  sentinel  should  be  placed  at  each  sink  or  closet  with  positive  instructions 
for  its  enforcement. 

5.  Tents. — All  tents  should  have  a  flooring  raised  at  least  6  inches  above  the 
ground,  and  if  practicable  the  soldiers  should  be  provided  with  cots.  All  bedding 
and  blankets  should  be  daily  exposed  to  the  direct  sunlight.  Men  should  be  com- 
pelled to  remove  their  outer  clothing  at  night.  The  floors  of  all  the  tents  should 
be  kept  clean. 

G.  Regimental  hospital. — All  men  with  fever  should  be  immediately  removed  to 
the  hospital.  The  most  thorough  disinfection  of  the  stools  and  urine  of  all 
patients  under  treatment  in  the  hospital,  and  of  all  bed  clothing  and  personal 
linen  should  be  required  as  a  matter  of  routine.  This  recommendation  shou'd 
apply  not  only  to  all  fever  patients  but  also  to  all  others.  For  the  purposes  of 
disinfection  a  solution  consisting  of  1  part  of  carbolic  acid  to  30  parts  of  water 
should  be  prepared  in  large  quantities  and  stored  in  barrels  readily  accessible  as 
the  sole  disinfectant.  A  pint  of  this  should  be  placed  in  each  b  dpan  before  it 
receives  the  discharge  from  the  patient;  when  the  bedpan  is  removed  an  addi- 
tional pint  of  the  solution  should  be  added  and  the  vessel  carried  to  the  sink, 
emptied,  and  afterwards  thoroughly  washed  with  the  same  dis-nfecting  solution. 
After  each  stool  the  patient's  buttocks  should  be  carefully  cleansed  with  this  solu- 
tion. Whenever  any  fecal  matter  is  spilled  upon  the  floors  or  ground  the  s;  ot 
should  be  immediately  cleaned  and  disinfected  with  this  solution.  All  soiled  per- 
sonal and  bed  linen  should  be  immediately  removed  and  at  once  immersed  in 
the  same  carbolic  solution  for  at  least  two  hours.  Mattresses,  bed  linen,  and 
blankets  should  be  daily  exposed  to  the  direct  sunlight  when  not  in  use.  All  hos- 
pital-tent floors  should  be  scrubbed  daily  with  this  solution.  The  greatest  atten- 
tion should  be  paid  to  the  disinfection  and  condition  of  the  hospital  sink,  in  addition 
to  the  thorough  disinfection  of  all  stools;  lime  and  dry  earth  should  be  thrown 
into  the  sinks.  The  possibility  of  flies  gaining  access  to  any  fecal  matter  in  the' 
sinks  should  be  absolutely  prevented  by  this  means.  Attendants  should  be 
required  to  disinfect  their  hands  after  attending  each  patient  in  each  instance. 
The  recommendations  made  with  reference  to  the  company  mess  tents  and 
kitchens  apply  with  special  force  to  the  hospital  mess  tents  and  kitchens. 

The  foregoing  apparently  minute  details  concerning  water  supply,  mess  tents 
and  kitchens,  garbage,  company  sinks,  tentage,  and  hospital  must  be  carried  out 
in  every  particular  if  typhoid  fever,  already  present  in  this  command,  is  to  be 
stamped  out.  We  therefore  recommend  that  each  one  of  these  sanitary  regula- 
tions be  placed  upon  the  status  of  military  discipline,  and  that  an  infraction  of 
any  of  them  be  as  severely  punished  as  any  other  breach  of  discipline.  In  no 
other  way  can  immunity  be  secured  to  this  regiment  of  "  immunes. " 

Very  respectfully, 

.  Walter  Heed, 
Major  and  Surgeon,  U.  S.  V, 
Victor  C.  Vaughan, 
Major  and  Division  Surgeon,  U.  S.  V; 

E.  O.  Shakespeare, 
Major  and  Brigade  Surgeon,  U,  S,  V. 
Brig.  Gen.  H.  V.  Boynton, 

Camj)  George  H.  Thomas,  Chichamauga  Park,  Georgia. 
7273 4 


50 

Subsequently  we  recommended  tliat  tlie  galvanized-iron  boxes  pre- 
pared by  our  board  and  adopted  by  the  Surgeon-General  should  be 
used  in  place  of  sinks. 

After  inspecting  the  Second  Division  of  the  First  Army  Corps  at 
Knoxville,  the  board  made  the  following  report: 

Knoxville,  Tenn,,  Septeviber  16,  1898. 
Sir:  The  board  of  medical  officers  convened  per  Special  Orders,  No.  194,  para- 
graph. 40,  Adjutant-General's  Office,  Washington,  D.  C,  August  18,  1898,  respect- 
fully submit  the  following  recommendation  in  compliance  with  the  provisions  of 
said  orders: 

1.  Water  supply. — As  far  as  the  board  has  been  able  to  judge  the  water  supply- 
appears  to  be  of  good  quality.  The  supply  of  the  city  of  Knoxville  proper  has 
been  used  by  the  Fourth  Tennessee  Volunteer  Infantry  for  more  than  two  months, 
and  although  there  are  a  few  cases  of  typhoid  fever  in  this  regiment,  these  are 
plainly  not  due  to  water  contamination.  The  supply  of  West  Knoxville  is  pre- 
sumably of  good  quality. 

2.  (a)  Kitchen  sinks. — All  garbage  should  be  received  into  water-tight  barrels 
and  carried  away  from  the  camps  daily;  wash  water  should  be  thrown  into  pits  to 
which  dry  earth  and  ashes  are  daily  used  for  covering.  As  a  rule,  kitchen  sinks 
have  been  found  in  good  sanitary  condition.  The  best  cared-for  kitchen  sinks  are 
those  of  the  First  West  Virginia  and  Sixth  Ohio;  the  worst  those  of  the  Thirty- 
first  Michigan,  Second  Ohio,  First  Pennsylvania,  and  Fourteenth  Minnesota. 
Earth  should  be  placed  in  the  sinks  whenever  fluid  garbage  is  emptied  into  them. 
There  is  needed  frequent  inspection  of  these  sinks  by  company  and  medical  offi- 
cers to  insure  a  good  sanitary  condition. 

(&)  Company  sinks. — With  the  presence  of  typhoid  fever  among  the  men  of 
every  regiment  constituting  this  division,  except  the  Sixth  A^irginia  Infantry  (a 
recently  I'ecruited  regiment),  the  board  must  express  considerable  surprise  that 
so  little  attention  is  given  to  the  condition  of  these  sinks;  not  one  was  found  to  be 
properly  cared  for;  exposed  fecal  matter,  with  attendant  flies,  was  found  in  every 
sink.  The  sinks  of  the  Sixth  Ohio  were  in  the  best  condition;  the  remainder  were 
foul  and  offensive.  This  condition,  a  con.«itant  menace  to  health,  should  not  be 
tolerated  any  longer.  Every  soldier  in  this  command  should  be  compelled  to 
cover  with  dry  earth  his  excrement  as  soon  as  deposited.  In  no  other  way  can 
sinks  be  kept  in  a  safe  and  sanitary  condition.  If  necessary  to  enforce  this  order 
sentinels  should  be  placed  near  each  sink  to  see  that  men  cover  at  once  their 
excrement.  The  proposal  to  keep  sinks  dark  is  not  considered  advisable.  Light 
should  be  admitted  so  that  the  sink  can  be  inspected  at  all  times.  Once  each  day 
lime  shouM  be  freely  used  to  cover  the  margins,  sides,  and  bottoms  of  all  sinks.  In 
the  opinion  of  the  board  no  sanitary  measure  is  so  important  for  the  health  of  this 
command  as  such  care  of  sinks  as  has  been  recommended  above.  At  the  inspec- 
tion made  this  day  of  the  camp  site  of  the  Sixth  Virginia  and  Third  North  Caro- 
lina Infantry,  it  was  found  that  the  men  of  both  of  these  regiments  were  using  the 
abandoned  sinks  of  the  First  Pennsylvania  Regiment.  Tliese  sinks  were  found  to 
be  in  an  indescribably  filthy  condition,  disgraceful  to  any  command;  not  even  a 
shovelful  of  earth  had  been  placed  in  any  sink.  If  such  condition  of  the  sinks  of 
this  command  is  to  be  permitted,  then  all  efforts  to  stamp  out  typhoid  fever  will 
be  of  no  avail.  Already  typhoid  fever  has  appeared  among  the  men  of  one  of 
these  regiments  (Third  North  Carolina). 

We  visited  the  camp  of  the  Fourth  Tennessee  with  considerable  interest,  as  we 
had  understood  that  this  regiment  had  so  far  escaped  typhoid  fever.  However, 
we  found  they  had  already  had  1  death  from  this  disease,  and  there  are  now  2 
cases  of  typhoid  fever  in  their  regimental  hospital.     This  command  has  a  regi- 


■      51 

mental  sink  to  which  no  attention  is  ffiven,  and  its  condition  is  such  as  to  practi- 
cally guarantee  the  distribution  of  typhoid  fever  throughout  the  regiment.  We 
learn  that  this  regiment  intends  to  adopt  the  "  tub  "  system  of  disposing  of  fecal 
matter.  If  there  be  any  form  of  disposition  of  fecal  matter  more  dangerous  to 
the  soldier  than  the  unkept  sink  it  is  the  tub.  We  have  seen  abundant  evidence 
of  this  in  the  Seventh  Army  Corps.  The  tub  is  a  portable  privy,  often  laden  with 
typhoid  infection,  which  is  scattered  from  the  privy  to  the  place  where  the  matter 
is  deposited.  We  beg  to  protest  most  earnest  y  against  the  tub  system.  We  sug- 
gest that  battalion  sinks  be  properly  constructed  and  property  cared  for  in  this 
regiment.  If  this  be  done  there  is  the  possibility  of  stamping  out  the  dJsease, 
We  feel  quite  certain  that  the  medical  officer  of  this  regiment  will  fail  to  recog- 
nize typhoid  fever  in  its  early  stage.  We  therefore  recommend  that  the  sanitary 
inspector  visit  this  regiment  at  least  twice  each  week,  and  that  he  not  only  inspect 
the  sinks,  but  also  examine  the  patients  in  the  regimental  hospital  and  in  quarters, 
and.  should  new  cases  appear,  this  regiment  should  be  immediately  moved  to 
another  site.  This  suggestion,  that  the  sanitary  inspector  look  after  regimental 
hospitals,  should  apply  to  all  regiments  having  such  hospitals.  He  should  see 
that  the  stools  of  all  patients  in  these  hospitals  are  properly  disinfected.  Unless 
constant  attention  be  given  to  the  care  of  sinks  and  the  disinfection  of  stools,  the 
experience  at  Chickamauga  will  be  repeated  at  Knoxville. 

3.  The  division  hospital. — The  board  made  an  inspection  of  this  hospital  on  the 
14th  instant.  The  number  of  patients  on  this  date  was  about  235.  The  wards 
were  found  to  be  overcrowded,  as  many  as  7  or  8  patients  being  in  each  tent.  The 
floors  of  the  general  pavilion,  as  well  as  of  the  tents,  were  in  a  filthy  condition. 
As  far  as  the  board  was  able  to  judge  by  inspection  and  by  questioning  the  nurses, 
no  attention  was  paid  to  the  disinfection  of  either  stools  or  personal  or  bed  linen. 
Patients  with  garments  soiled  with  typhoid  discharges  were  found  in  one  of  the 
wards.  Bedpans  used  for  the  patients  were  soiled  with  discharges  not  disinfected. 
Open  vessels  containing  the  nondisinfected  discharges  of  typhoid  patients  were 
being  carried  from  the  wards  to  the  sink,  there  emptied  without  disinfection,  and 
the  contents  allowed  to  drop  upon  the  surrounding  ground.  The  sink  intended 
for  the  reception  of  typhoid  discharges  was  very  offensive.  The  margins  and 
sides  of  the  sink  were  in  like  condition.  It  was  evident  upon  inspection  that  the 
surgeon  in  charge  had  no  appreciation  of  the  need  of  disinfection  of  stools  or  linen 
or  of  the  need  of  cleanliness  in  the  hospital.  The  board  found  the  number  of 
nurses  to  be  insufficient.  In  the  opinion  of  the  board  no  tinxe  should  be  lost  in 
securing  the  services  of  trained  female  nurses  for  this  hospital,  in  order  to  enable 
proper  care  and  attention  to  be  given  to  the  sick. 

The  most  thorough  disinfection  of  all  stools  and  urine  of  all  patients  under 
treatment  in  the  hospital,  and  of  all  bed  clathing  and  personal  linen,  should  be 
required  as  a  matter  of  routine.  This  recommendation  should  apply  not  only  to 
all  fever  patients,  but  also  to  all  others.  For  the  purposes  of  disinfection,  a  solu- 
tion consisting  of  one  part  of  carbolic  acid  to  thirty  parts  of  water  should  be 
prepared  in  large  quantities  and  stored  in  barrels  readily  accessible  as  the  sole 
disinfectant.  A  pint  of  this  should  be  placed  in  each  bedpan  before  it  receives  the 
discharge  from  the  patient.  When  the  bedpan  is  removed  an  additional  pint  of 
the  solution  should  be  added  and  the  vessel  carried  to  the  sink,  emptied,  and  aftei'- 
wards  thoroughly  washed  with  the  same  disinfectant  solution.  After  each  stool 
the  patient's  buttocks  should  be  carefully  cleansed  with  the  same  disinfectant 
solution.  Whenever  any  fecal  matter  is  spilled  upon  the  floors  or  groimd,  the 
spot  should  be  immediately  cleaned  and  disinfected  with  this  solution.  All  soiled 
personal  and  bed  linen  should  be  imiaiediately  removed  and  at  once  immersed 
in  the  same  carbolic  solution  for  at  least  two  hours.  Mattresses,  bed  linen,  and 
blankets  should  be  daily  exposed  to  the  direct  sunlight  when  not  in  use.    All  hos- 


52      ■ 

pital  tent  floors  should  be  scrubbed  daily  with  this  solution.  The  greatest  atten- 
tion should  be  paid  to  the  disinfection  and  condition  of  the  hospital  sink.  In 
addition  to  the  thorough  disinfection  of  all  stools,  lime  and  dry  earth  should  be 
thrown  into  the  sinks.  The  possibility  of  flies  gaining  access  to  any  fecal  matter 
in  the  sinks  should  be  absolutely  prevented  by  this  means.  Attendants  should  be 
required  to  disinfect  their  hands  after  attending  each  patient  in  each  instance. 

The  board,  especially  recommends  as  an  important,  sanitary  measure  that  men 
with  fever  should  be  immediately  removed  from  their  regimental  quarters  or 
regimental  hospital  to  the  division  hospital.  Under  no  circumstances  should  the 
men  with  fever  be  permitted  to  occupy  the  tents  with  their  comrades. 

J^.  Camp  sites. — Since  it  is  true  that  every  regiment  in  this  division  has  been 
and  is  infected  with  typhoid  fever,  it  follows  that  the  ground  upon  which  each 
and  every  regiment  has  been  or  is  located  is  also  infected.  We  therefore  deem  it 
very  unwise  to  encamp  a  regiment  upon  sites  vacated  by  those  leaving.  The  tent 
'  floors  left  by  the  First  Pennsylvania  are  now  being  used  by  the  Sixth  Virginia. 
This  should  not  be  done  until  these  floors  have  been  washed  with  a  5  per  cent  solu- 
tion of  carbolic  acid  and  afterwards  exposed  to  the  direct  rays  of  the  sun  for  at 
least  two  days. 
The  foregoing  recommendations  are  respectfully  submitted. 

Walter  Reed, 
Major  and  Surgeon,  U,  8.  A. 
Victor  C.  Vaughan, 
Major  and  Division  Surgeon,  U.  S.  V. 
The  Adjutant-General  Second  Division,  First  Army  Corps, 

Camj)  Poland,  Knoxville,  Tenn. 

In  extenuation  of  the  condition  of  tiie  camps  at  Chickamauga,  it  lias 
been  stated  that  all  of  the  regiments  there  were  on  waiting  orders,  and 
expected  every  day  that  they  would  start  the  next  for"  Cuba  or  Porto 
Rico.  This  is  true,  but  it  should  not  be  ofEered  in  extenuation  of  the 
condition  of  the  camps.  Every  camp,  even  when  it  is  to  be  occupied 
for  only  a  daj^,  should  be  policed  as  thoroughly  as  if  the  commanding 
officer  knew  that  he  was  to  remain  there  for  weeks. 

Shelter,  occupancy,  and  arrangement  of  camps. — On  this  point  we 
will  copy  verbatim  from  the  report  of  Lieutenant-Colonel  Woodhull, 
who  inspected  the  troops  at  Chickamauga  in  August : 

All  the  troops  are  under  canvas  and  nearly  all  the  canvas  is  overcrowded.  The 
tents  are  of  many  patterns — a  few  shelter,  more  conical  and  conical  wall;  some 
State  tents  of  various  sizes,  the  most  of  which  are  so-called  •'  flood"  tents  of  the 
Mississippi  Valley,  very  old  and  nearly  all  leaky,  and  the  greater  part  the  improved 
common  or  A  wall  tent.  The  occupants  vary  from  3  in  the  shelter  to  4  and  5 
in  the  A,  6  or  8  in  the  •'  flood.''  and  15  or  16  in  the  conical. 

Many  of  the  regimental  sites  are  precisely  the  same  as  those  occupied  from  the 
beginning.  A  few  of  the  regiments  have  been  moved,  and  it  is  probable  that 
more  are  now  being  changed,  but  at  the  time  of  my  observation  many  of  the  com- 
mands had  been  in  absolutely  the  same  position  for  two  months  or  more.  Not 
only  were  the  camp  sites  the  same,  but  in  the  most  instances  the  tents  themselves 
stood  where  they  had  first  been  placed.  In  scarcely  any  instance  was  fresh  ground 
available,  as  it  should  be,  upon  which  the  tents  might  be  moved  laterally  every 
week  or  ten  days.  Consequently  the  ground  itself  is  being  poisoned  impercepti- 
bly but  persistently  bj^  the  human  body  without  the  disinfectant  and  redeeming 
action  of  direct  sunlight  upon  it.  The  contents  of  the  tents,  such  as  blankets, 
straw,  and  the  like,  have  been  irregularly  removed  into  the  open  air,  but,  as  a 


53 

rule,  not  often  enough.  Direct  touch  showed  in  many  instances  that  these  articles 
and  the  ground  were  damp. 

The  camps,  speaking  generally,  were  crowded  not  merely  as  to  inhabitants  but 
as  to  the  neighborhood.  There  was  abundant  room  between  divisions  and  gener- 
al J- between  brigades,  but  many  of  the  brigade  camps  were  too  compressed,  and  with 
some  of  the  regiments  the  compression  was  extreme  and  in  defiance  of  all  sanitary 
laws;  this  in  addition  to  the  tents  themselves  having  too  many  occupants.  The  diffi- 
cu  ty  probably  arose  originally  from  the  expectation  that  many  more  troops  would 
be  sent  into  the  park  for  whom  space  must  be  reserved.  In  some  cases  higher 
authority  arbitrarily  established  the  regimental  lines.  Whatever  the  reason,  the 
effect  is  clear — the  tents  are  overcrowded  and  without  sufficient  adjoining  space, 
the  streets  are  narrow,  and  the  sod  is  becoming  more  and  more  charged  with 
Lltli.  Owing  to  reasons  previously  explained  competent  sinks  were  made  with 
difficulty  and  were  multiplied  on  account  of  their  shallowness  and  the  rapidity 
with  wh'ch  they  filled  with  water.  They  thus  encroached  more  and  more  upon 
the  open  space  and  intruded  toward  the  camps.  For  instance,  in  the  Second 
Arkansas,  Second  Brigade,  Second  Division,  Third  Army  Corps,  the  men's  sinks 
were  within  30  yards  of  the  kitchens,  and  were  very  offensive.  The  kitchen  sinks 
were  intermediate  and  so  full  and  so  foul  that  maggots  were  abundant  on  the 
surface.  In  the  Fifth  Pennsylvania  the  camp  site  was  lower  than  the  sinks,  and 
during  recent  rains  they  overflowed  and  flooded  the  camp.  The  sick  report  of  the 
regiment  was  11  per  cent,  including  25  cases  recognized  as  typhoid  and  15  supposed 
to  be  of  that  disease,  with  the  sick  rate  increasing. 

More  than  half  of  the  men  slept  on  the  ground.  In  some  regiments  the  tents 
were  floored,  in  others  cots  and  field  bedsteads  were  arranged,  but  always  at 
private  or  regimental  expense.  The  motive  in  manyins'^ances  doubtless  wascom- 
fort,  but  in  one  regiment  (Third  Tennessee)  the  men  bought  the  cots  because  they 
had  learned  by  eiperierience  in  civil  life  that  it  was  harmful  to  sleep  on  the 
ground  in  that  climate.  In  a  -very  sickly  regiment  (Ninth  Pennsylvania)  the 
medical  officer  pointed  out  a  very  high  three-story  bunk,  whose  tenants  he  d  c  ared 
the  healthiest  in  the  command.  A  group  of  three  is  too  small  to  reason  from,  but 
it  is  significant  that  among  much  sickness  these  men  escaped.  The  sanitary 
advantage  of  being  off  the  ground  is  freedom  from  dampness,  and  especiallj'  escape 
from  the  immediate  influence  of  the  ground  air,  which  under  the  conditions 
described  must  be  peculiarly  deleterious.  It  is  recommended  that  in  all  camps  of 
position  in  Southern  climates  the  tents  be  floored,  with  a  consideraijle  space 
beneath,  and  that  the  floors  be  portable,  so  that  they  may  be  moved  (within  the 
camp)  when  necessary  for  change  of  site  or  for  police.  The  expenditure  for  a  lew 
feet  of  lumber  when  the  regiment  departs  is  well  balanced  by  the  greater  physical 
efficiency  of  the  men. 

Quite  independently  of  any  specific  contamination  of  the  water  supply  (and 
were  the  general  water  supply  thus  contaminated  the  typhoid  fever  would  also  be 
general,  which  it  is  not  as  yet),  the  pollution  of  the  soil  by  fecal  discharges,  spe- 
cifically diseased  or  healthful,  leads  to  the  occurrence  of  diarrhea,  to  general 
physical  depression,  moderate  fever,  and  undermining  the  man's  health,  and 
whether  an  imported  case  or  not  is  necessary  to  fire  the  train,  it  is  the  universal 
experience  of  armies  that  outbreaks  of  typhoid  fever  will  occtir  under  just  such 
circumstances.  This  is  perfectly  understood  and  always  anticipated  bj^  sani- 
tarians where  precautionary  measures  are  not  carried  into  effect.  In  this  case, 
besides  having  a  coni^enial  soil  fertilized  day  by  day  for  such  seed,  the  seed  itself 
was  introduced  directly  by  various  regiments,  as  Thirty-first  Michigan,  First 
South  Carolina  (as  reported,  regiment  has  left  the  park).  Fifty-second  Iowa, 
which  brought  no  acute  case  but  was  infected  beiore  arrival,  and  Ninth  Penn- 
sylvania, which  has  bad  nearly  100  cases  in  all.  Besides  which,  certain  regiments 
(Fourteenth  Minnesota,  Second  Ohio,  Third  United  States  Volunteer  Cavalry) 


54 

have  treated  cases  for  considerable  periods  in  tJae  camps  themselves.  It  can  not 
be  necessary  to  enlarge  on  the  facilities  for  the  spread  of  this  disease  that  are 
afforded  by  fatigue,  heat,  moisture,  overcrowding,  dust,  and  flies,  and  all  these 
are  present. 

The  following  figures   give  tlie  most    important   facts  concerning 
typhoid  fever  in  the  First  and  Third  Army  CorxDS: 

FIRST  ARMY  CORPS. 
[Note. — The  regiments  marked  *  went  to  Porto  Rico.] 


Comm.ands. 


OS  sS 
•V  o 


com 

sal 

S  03  1^ 


FIRST   DIVISION. 

First  Brigade. 

*lst  Kentucky. 

*3d  Wisconsin - - 

5th  Illinois _ 

Second  Brigade. 

*4thOhio -. 

*3d    Illinois.- 

*  4th  Pennsylvania 

Third  Brigade. 

*  16th  Pennsylvania 

*2d   Wisconsin-- 

3d    Kentucky 

SECOND   DIVISION. 

F'irst  Brigade. 

31st  Michigan. 

iBUth  Indiana 

1st  Georgia 

Second  Brigade. 

158th  Indiana 

6th  Ohio 

1st  West  Virginia 

Third  Brigade. 

1st  Pennsylvania 

1-tth  Minnesota 

3d    Ohio 

THIRD   DIVISION. 

First  Brigade. 

.5th  Pennsylvania 

12th  Minnesota- 

1st  South  Carolina 

Second  Brigade. 

8th  Massachusetts  _ 

21st  Kansas .   ... 

12th  New  York 

Third  Brigade. 

3d    Missouri 

1st  New  Hampshire 

9th  Pennsylvania 


263 
378 
125 


546 


329 

219 


239 
233 
120 


128 
291 


332 
286 
403 


338 
433 


373 
294 
490 


268 
397 
334 


19.80 

38.78 
9.64 


41.33 


24.81 
16.93 


18.52 
16.99 


9.93 
23.40 
20.03 


20.72 
22.39 
31.07 


36.18 
33.33 


20.65 
33. 35 
37,63 


31.11 
33.  40 

35.87 


107 
113 


149 


113 

219 


49 

148 
106 


169 
146 
192 


153 
144 


157 
95 
144 


181 
213 
155 


16 


6.87 
6.34 
6.04 


4.57 


8.20 
5.02 


6.69 
5.58 
7.50 


7.81 
6.52 
4.61 


5.40 
3.  49 
3.23 


4.73 
4.38 


7.00 
7  14 
4.00 


7.08 
10.00 

7.78 


55 


THIRD  ARMY  CORPS. 


Commands. 


FIRST  DIVISION. 

First  Brigade. 


14th  New  York. 
1st  Missouri. -- 
5th  Maryland  - 


Second  Brigade. 


2d    Nebraska  _ 

2d    New  York 

1st  District  of  Columbia 


Third  Brigade. 


3d  Tennessee - 
1st  Vermont .- 
8th  New  York. 


SECOND  DIVISION. 
First  Brigade. 


2d  Kentucky . 
9th  New  York. 
1st  Arkansas.. 


Second  Brigade. 


5th  Missouri  . . 
2d  Arkansas.. 
69th  New  York. 


Third^  Brigade. 

1st  Maine 

52d   Iowa... , 

1st  Mississippi 


CAVALRY  BRIGADE. 


3d  U.  S.  Volunteer  Cavalry... 
1st  Illinois  Volunteer  Cavalry. 
1st  Ohio  Volunteer  Cavalry 


Light  Artillery  Brigade 

6th  17.  S.  Volunteer  Infantry 


1,277 

1,275 

985 


1,303 

1,014 

942 


1,293 

996 

1,301 


1,332 
1,292 
1,290 


1,274 
1,291 
i;026 


1,286 
1,304 
1,029 


1,013 

1,299 

8a3 


S  =s 

a© 


233 
216 
250 


167 
161 


123 
278 
425 


286 
323 

228 


212 
287 
299 


188 
345 
397 


270 
220 


133 


18.24 
16.94 
25.38 


12.81 
15.87 


9.51 
27.91 
32.66 


21.47 
25.00 
17.67 


16.64 
22.23 
29.14 


14.61 
26.45 
38.58 


26.65 
16.93 

22.68 


o  S 


95 

46 
147 


61 

84 
190 


87 
139 
83 


51 
95 
191 


184 


103 


121 


21 


-a  o 


+3  a  . 

fl  o  « 

©  .-i  ^ 

?  S  j§ 

O  c3  O 
Oh 


10.30 
5. 09 
6.80 


14.37 
18.63 


9.75 
7.91 
5.17 


9.79 

14.24 

8.33 


6.60 
5.93 
7.69 


23.93 

10.43 

7.30 


4.81 
7.27 
3.70 


3.75 


•^  u  ^ 
o  z.  ^ 


In  the  above  tables  the  figures  showing  the  strength  of  each  regi- 
ment are  not  absolutely  correct.  In  most  cases  the  figures  are  those 
that  indicate  the  strength  of  the  regiment  when  it  left  Chiekamauga. 
For  the  purposes  for  which  these  tables  were  compiled  it  would  have 
been  better  if  we  could  have  given  the  total  number  of  individuals  con- 
nected with  each  regiment,  but  figures  showing  this  fact  are  not  at 
our  command. 

In  coming  to  conclusions  concerning  typhoid  fever  among  the  troops 
of  these  corps,  it  will  be  necessary  to  leave  out  of  consideration  the 
seven  regiments  of  the  First  Division  of  the  First  Army  Corps  that 
went  to  Porto  Rico,  because,  as  has  already  been  stated,  undoubtedly 
a  considerable  proportion  of  the  cases  of  protracted  fever  in  these 


56 

regiments  were  malarial,  and  from  the  data  at  our  command  we  liave 
been  unable  with  any  certainty  to  distinguish  the  malarial  from  the 
typhoid  fevers  in  the  cases  originating  in  Porto  Rico.  From  the 
death  rate  in  these  commands  we  believe  tha^  we  have  not  overesti- 
mated the  number  of  cases  of  typhoid  fever  in  them.  However,  we 
think  it  best,  on  account  of  the  uncertainty  in  the  data  among  these 
regiments,  to  leave  them  out  of  consideration  in  making  general  state- 
ments concerning  the  statistics  of  typhoid  fever  in  the  First  and  Third 
Army  Corps. 

There  were  only  two  regiments  (Fifth  Illinois  and  Third  Kentucky) 
of  the  First  Division  of  the  First  Army  Corps  that  did  not  go  to  Porto 
Rico. 

These  two  regiments  had  a  combined  strength  of . .  _ 2, 589 

Total  number  of  cases  of  probable  typhoid  fever  in  these  two  regiments 344 

Percentage    of   probable  typhoid  fever   among  the  troops  of  these  two 

regiments 13.28 

Total  number  of  deaths  from  typhoid  fever  in  these  two  regiments . .  19 

Percentage  of  deaths  among  cases  of  probable  typhoid  fever  in  these  two 

regiments...  . , 5.52 

We  can  not  give  the  total  number  of  cases  of  recognized  typhoid 
fever  in  these  two  regiments  on  account  of  having  no  data  on  this 
point  for  the  Third  Kentucky. 

Aggregate  strength  of  the  Second  Division  of  the  First  Army  Corps 11, 344 

Total  number  of  cases  of  j)roba.ble  typhoid  fever  in  the  Second  Division  of 

the  First  Army  Corps 2, 172 

Percentage  of  probable  typhoid  fever   among  the  troops  of  the  Second 

Division  of  the  First  Army  Corps .- 19.14 

Total  number  of  deaths  from  typhoid  fever  in  the  Second  Division  of  the 

First  Army  Corps .  -  - .• 109 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  in  the  Second 

Division  of  the  First  Army  Corps '. .   . . . . . 5. 01 

Total  number  of  cases  of  recognized  typhoid  fever  in  the  Second  Division 

of  tiie  First  Array  Corps __- 979 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever  in  the  Second 

Division  of  the  first  Army  Corps -.. .-- -      11.13 

In  studying  the  Third  Division  of  the  First  Army  Corps,  it  will  be 
necessary  to  omit  the  First  South  Carolina,  which  remained  at  Chicka- 
mauga  only  a  few  days. 

Aggregate  strength  of  the  eight  regiments  of  the  Third  Division  of  the 
First  Army  Corps 10,303 

Total  number  of  cases  of  probable  typhoid  fever  in  the  eight  regiments  of 
the  Third  Division  of  the  First  Army  Corps . .  - . . 2, 726 

Percentage  of  probable  typhoid  fever  among  the  troops  of  the  eight  regi- 
ments of  the  Third  Division  of  the  First  Army  Corps    ■. 26. 46 

Total  number  of  deaths  from  typhoid  fever  in  the  eight  regiments  of  the 
Third  Division  of  the  First  Army  Corps  _ 170 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  in  the  eight 
regiments  of  the  Third  Division  of  the  First  Army  Corps 6. 23 


57 

Total  number  of  cases  of  recognized  typhoid  fever  in  the  eight  regiments 
of  the  Third  Division  of  the  First  Army  Corps 1, 241 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever  in  the 
eight  reg.ments  of  the  Third  Division  of  the  First  Army  Corps 13. 69 

In  studying  the  First  Division  of  the  Third  Army  Corps,  it  will  be 

necessary  to  omit  the  First  District  of  Columbia  Volunteers,  because 

this  command  remained  at  Chickamauga  only  a  few  days. 

Aj-'gregate  strength  of  the  eight  regiments  of  the  First  Division  of  the 

Til. rd  Army  Corps - 9,444 

Total  number  of  cases  of  probable  typhoid  fever  in  the  eight  regiments  of 
the  First  Division  of  the  Third  Army  Corps 1, 853 

Percentage  of  probable  typhoid  fever  among  Ihe  troops  of  the  eight  regi- 
ments of  the  First  Division  of  the  Third  Army  Corps 19. 62 

Total  number  of  deaths  from  typhoid  lever  in  the  eight  regiments  of  the 
First  Division  of  the  Third  Army  Corps 160 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  in  the  eight 
regiments  of  the  First  Division  of  the  Third  Army  Corps ...       8. 63 

Total  number  of  cases  of  recognized  typhoid  fever  in  the  eight  regiments 
of  the  First  Division  of  the  Third  Army  Corps  ._. 725 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever  in  the  eight 
regiments  of  the  First  Division  of  the  Third  Army  Corps 22. 06 

Aggregate  strength  of  the  nine  regiments  of  the  Second  Division  of  the 

Third  Army  Corps ...     11, 124 

Total  number  of  cases  of  probable  typhoid  fever  in  the  nine  regiments  of 
the  Second  Division  of -the  Third  Army  Corps 2, 565 

percentage  of  probable  typhoid  fever  among  the  troops  of  the  nine  regi- 
ments of  the  Second  Division  of  the  Third  Army  Corps ? 23. 05 

Total  number  of  deaths  from  typhoid  fever  in  the  nine  regiments  of  the 
Second  Division  of  the  Third  Army  Corps .... ^ 257 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  in  the  nine 
regiments  of  the  Second  Division  of  the  Third  Army  Corps 10. 01 

Total  number  of  cases  of  recognized  typhoid  fever  in  the  nine  regiments 
of  the  Second  Division  of  the  Third  Army  Corps: ... 1,016 

Percentage  or  deaths  among  recognized  cases  of  typhoid  fever  in  the  nine 
regiments  of  the  Second  Division  of  the  Third  Army  Corps  . . 25. 29 

Aggregate  strength  of  the  First  and  Third  Army  Corps,  excluding  the 
regiments  that  went  to  Porto  Rico  from  the  First  Division  of  the  First 
Army  Corps,  the  First  South  Carolina  from  the  Third  Division  of  the 
First  Army  Corps,  and  the  First  District  of  Columbia  Volunteers  from 
the  First  Division  of  the  Third  Army  Corps .  _  _  44, 803 

Total  number  of  cases  of  probable  typhoid  fever  among  these  troops 9, 660 

Percentage  of  probable  typhoid  fever  among  these  troops ... 21. 56 

Total  number  of  deaths  from  typhoid  fever  among  these  troops 714 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  among  these 
troops ... 7. 40 

Total  number  of  cases  of  recognized  typhoid  fever  among  these  troops 4, 293 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever  among 
these  troops . .  . . - 16. 65 

If  to  the  above  figures  we  add  those  of  the  Cavalry  Brigade,  we  have 
the  following: 
Total  number  of  troops  in  the  First  and  Third  Army  Corps  for  which 

statistics  concerning  typhoid  fever  have  been  collected 47, 948 


58 

Total  number  of  cases  of  probable  typhoid  fever  among  these  troops 10, 339 

Percentage  of  probable  typhoid  fever  among  these  troops _  21 .  56 

Total  number  of  deaths  from  typhoid  fever  among  these  troops . 751 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  among  these 

troops • 7.26 

Total  number  of  cases  of  recognized  typhoid  fever  among  these  troops 4,  658 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever  among  these 

troops '_- 16.14 

We  are  without  sufficient  data  to  enable  us  to  add  to  the  figures 
those  from  the  Light  Artillery  Brigade  and  from  the  Sixth  XJ.  S.  Vol- 
unteer Infantry. 

We  have  used  one  statement  in  all  of  these-  compilations  which, 
without  proper  explanation,  may  be  misunderstood.  We  have  given 
the  percentage  of  deaths  among  recognized  cases  of  typhoid  fever. 
We  have  already  called  attention  to  the  fact  that  the  statement  of 
this  percentage  is  not  altogether  correct,  because  all  the  deaths  from 
tyi^hoid  fever  did  not  occur  among  recognized  cases  of  typhoid  fever. 
It  may  be  of  interest  to  inquire  how  the  regimental  and  hospital  sur- 
geons diagnosed  the  cases  which  terminated  f atallj"  from  typhoid 
fever.  The  714  deaths  given  in  the  above  figures  as  total  deaths  from 
tj^phoid  fever  in  the  First  and  Third  Army  Corps,  excluding  the  regi- 
ments that  went  to  Porto  Rico  from  the  First  Division  of  the  First 
Army  Corps,  the  First  South  Carolina  from  the  Third  Division  of  the 
First  Army  Corps,  the  First  District  of  Columbia  Volunteers  from  the 
First  Division  of  the  Third  Army  Corps,  and  the  Cavalry  Brigade  of 
the  First  Army  Corps,  were  not  all  diagnosed  typhoid  fever  by  army 
medical  officers.  By  looking  over  the  list  of  deaths  given  in  each 
regiment  one  easily  sees  that  a  considerable  number  of  these  deaths 
occurred  after  the  patients  had  reached  their  homes  on  furlough. 
Most  of  these  men  sent  home  on  furlough  are  recorded  in  the  regi- 
mental and  hospital  reports  as  haAdng  malaria,  or  they  were  sent  home 
without  any  definite  diagnosis.  Taking  the  714  cases  referred  to,' the 
recorded  diagnoses  of  these  cases  were  as  follows : 

Indigestion 4 

Gastritis 1 

Enteritis  ..- 1 


Pneumonia 1 

Total 714 


Typhoidfever 391 

Malaria  _ - 144 

Undiagnosed,  or  undetermined 

fever  . .  _ 141 

Diarrhea... 22 

Dysentery 9 

In  other  words,  in  4,293  cases  of  recognized  typhoid  fever  among 
these  troops  391  died.  After  studjdng  the  records  we  have  added 
5,367  cases  which  we  believe  to  have  been  typhoid  fever.  Among 
the  4,293  cases  of  recognized  typhoid  fever  there  were  391  deaths; 
among  the  5,367  cases  which  we  have  added  there  occurred  323  deaths 
from  typhoid  fever. 

Percentage  of  deaths  among  the  4.293  cases  of  recognized  typhoid  fever. 9. 10 

Percentage  of  deaths  from  typhoid  fever  among  the  5,367  cases  of  probable 

typhoid  fever - --  6. 01 


59 

This,  we  think,  is  the  strongest  proof  that  we  can  offer  that  the 
cases  which  we  have  classed  as  probable  typhoid  fever  are  properly 
classified.  The  death  rate  among  these  from  typhoid  fever  is  the 
death  rate  of  typhoid  fever.  As  has  already  been  stated,  most  of 
these  men  were  allowed  to  go  home  on  furlough.  They  were  granted 
furlough  on  the  diagnosis  of  some  other  disease  than  tyjahoid  fever. 
They  went  to  their  homes,  and  323  out  of  the  5,367  cases  died  from  a 
disease  recognized  by  the  physicians  who  attended  them  in  their  last 
illness  as  typhoid  fever.  We  think  that  these  figures  establish  beyond 
any  doubt  our  claim  that  the  number  of  cases  of  typhoid  fever  among 
the  troops  in  the  First  and  Third  Army  Corps  was  more  than  tMdce 
the  number  recognized  as  having  that  disease. 

Out  of  the__714  deaths  from  typhoid,  352  occurred  in  some  army 
hospital;  315  occurred  elsewhere,  principally  at  the  homes  of  the  men, 
and  in  47  cases  we  have  not  been  able  to  ascertain  the  place  of  death. 
Parenthetically  it  might  be  remarked  that  these  figures  show  that  the 
general  order  permitting  medical  officers  to  send  home  sick  men  on 
furlough  was  not  abused.  The  number  of  malingerers  must  have 
been  vqvj  small.  This  was  the  opinion  of  the  army  medical  officers 
at  Chickamauga  at  the  time.  Frequently  the  statement  was  made 
that  it  was  difficult  to  induce  the  men  to  accept  furloughs  until  they 
became  too  sick  to  travel.  All  those  who  saw  the  sick  returning  from 
Chickamauga  and  other  camps  during  the  summer  of  1898  must  have 
been  convinced  by  the  appearance  of  these  furloughed  soldiers  that 
they  were  in  reality  sick.  The  figures  which  we  have  just  given  con- 
firm this  Impression  with  mathematical  exactness. 

We  have  several  times  spoken  of  the  death  rate  of  typhoid  fever. 
It  may  be  well  to  endeavor  to  ascertain  what  the  death  rate  of  this 
disease  is.  It  is  well  known  that  ever  since  typhoid  fever  has  been 
recognized  as  a  distinct  disease  and  has  been  distinguished  from 
typhus  fever  the  death  rate  from  this  disease  has  gradually  decreased. 
This  decrease  in  the  death  rate  is  undoubtedly  due  to  two  causes.  In 
the  first  place,  the  diagnosis  of  the  disease  is  much  more  eas}^  than  it 
was  formerly  when  typhus  fever  was  so  prevalent;  in  the  second  place, 
the  methods  of  treatment  of  typhoid  fever  have  greatly  improved. 
Murchison  reported  2,505  cases  that  occurred  in  the  London  Fever 
Hospital  from  1848  to  1862,  with  a  death  rate  of  18.5  per  cent;  Grie- 
singer  collected  18,612  cases  from  the  hospitals  of  London,  Glasgow, 
Paris,  and  Strasburg  from  1840  to  1865,  and  found  a  death  rate  of 
18.52  per  cent;  in  the  Old  Hospital  in  Vienna,  from  1846  to  1861,  there 
were  21,189  cases  of  typhoid  fever,  with  a  death  rate  of  22.2  jper  cent; 
in  the  Jacob's  Hospital  in  Leipzig,  from  1880  to  1893,  there  were  1,626 
cases,  with  a  death  rate  of  12.7  per  cent;  in  the  citj^  of  Hamburg, 
during  the  years  1886  and  1887,  there  were  10,823  cases,  with  a  death 
rate  of  8.5  per  cent.  These  cases  were  divided  by  years  as  follows: 
In  1886,  3,948  cases,  with  a  death  rate  of  9.2  per  cent;  in  the  year 


60 

1887,  6,875  cases,  with  a  death  rate  of  6.9  percent.  In  1897  there  were 
1,885  cases  at  Maidstone,  England,  with  a  death  rate  of  7.5  per  cent. 
Brand  has  collected  19,017  cases  treated  by  cold  baths,  with  a  mor- 
tality of  7.8  per  cent. 

All  the  above  given  figures  have  been  obtained  from  European 
sources  and  refer,  many  of  them,  to  epidemics  more  or  less  remote  in 
time.  We  have  been  anxious  to  ascertain  the  mortality  from  typhoid 
fever  in  this  country  and  at  this  time.  In  order  to  get  information 
on  this  subject  we  have  addressed  a  request  to  the  superintendents  of 
several  of  the  largest  hospitals  in  the  United  States,  asking  for  the 
number  of  cases  of  tyj)hoid  fever  treated- in  the  years  1896  and  1897, 
and  the  number  of  deaths  in  each  of  these  years.  We  have  not  asked 
for  cases  in  1898,  because  we  wished  to  avoid  cases  among  soldiers. 
The  following  figures  have  been  obtained  in  response  to  this  request: 

Death  rate  from  typhoid  fever  in  sovie  of  the  larger  hospitals  in  the  United  States. 


Name  of  hospital. 

Number  of 
oases. 

Deaths. 

Total 
cases, 
1896, 
1897. 

Total 

deaths. 

1896, 

1897. 

Percent- 
age of 

1898. 

1897. 

1896. 

1897. 

deaths. 

City  Hospital,  Boston,  Mass 

437 

151 

153 

20 

64 

110 

33 

73 

105 

399 

100 

141 

36 

153 

116 

34 

76 

94 

44 
16 
13 

1 

7 
11 

1 
11 

8 

46 
8 

10 
3 

10 
3 
0 

11 
9 

836 
251 
294 

56 
217 
226 

66 
148 
199 

90 

24 
23 

4 
17 
14 

1 

23 
17 

10.76 

Massachusetts  General  Hospital,  Boston,  Mass- 

Episcopal  Hospital,  Philadelphia.  Pa 

University  Hospital,  Philadelphia,  Pa  .-_ 

9.  .56 

7.83 
7.14 

7.83 

Johns  Hopkins  Hospital,  Baltimore,  Md 

St  Luke's  Hospital,  New  York,  N.  Y    - 

6.19 
1.51 

Belle vue  Hospital,  New  York.  N.  Y 

Mount  Sinai  Hospital,  New  York,  N.  Y 

14.86 
8.54 

Total  number  of  cases  of  typhoid  fever  in  the  hospitals ....    ...    2, 293 

Total  number  of  deaths  among  the  cases  treated  in  these  hospitals 212 

Percentage  of  deaths  among  these  cases ^ 9. 24 


It  will  be  seen  from  these  figures  that  the  average  death  rate  from 
typhoid  fever  in  the  large  hospitals  is  a  little  more  than  9  per  cent. 
Bearing  in  mind  that  onl}^  graver  cases  are  carried  to  hospitals,  and  that 
the  cases  treated  in  hospitals  embrace  all  ages  and  conditions  of  life, 
while  the  soldiers  were  men  selected  on  account  of  physical  perfection, 
it  must  be  admitted  that  a  death  rate  of  7.49  per  cent  among  the 
10,339  probable  cases  of  typhoid  fever  in  the  First  and  Third  Army 
Corps  was  not  an  unusually  low  one. 

We  have  endeavored  to  ascertain  the  death  rate  from  typhoid  fever 
in  general  practice  in  some  of  the  largest  cities  of  the  Union.  With 
this  in  view,  we  directed  a  letter  to  the  health  commissioner  of  each 
of  these  cities.  Most  of  these  officials  replied  that  they  are  unable  to 
give  anything  more  than  the  number  of  deaths,  inasmuch  as  cases  of 
typhoid  fever  are  not  reported  to  the  health  authorities.  From  a 
few  cities  returns  have  been  furnished  us.  In  our  opinion  these  are 
whoUy  worthless  so  far  as  information  concerning  the  death  rate  from 


61 


typhoid   fever   is  concerned.     They   are,    however,    of    interest    for 
another  reason,  and  we  will  give  some  of  them : 

Death  rate  from  typhoid  fever  in  certain  cities  in  the  United  States. 


Is  ame  of  city. 


Year. 


Number 
of  eases. 


Number 

of 
deaths. 


Percent- 
age of 
deaths. 


Buffalo.N.y . 


Albany, N.Y 

Minneapolis,  Minn  . 

Pittsburg,  Pa 

Cleveland,  Ohio  — 

Richmond,  Va 

Duluth,  Minn 

St.  Louis,  Mo 

Philadelphia,  Pa  . . . 


1894 
1895 
1896 
1897 
1898 
1896 
1897 
1896 
1897 
1896 
1897 
1896 
1897 
1896 
1897 
1896 
1897 
1896 
1897 
1896 
1897 


397 

374 

201 

380 

438 

440 

.  43.5 

1,534 

1,216 

1,284 

296 

256 

51 

78 

785 

357 

348 

433 

3,490 

2,994 


185 


63 

98 

97 

84 

60 

148 

175 

184 

143 

73 


103 
33 
106 
124 
402 
401 


17.00 
34.68 
24.81 
31.34 
35.00 
32.14 
19.09 
13. 79 

9.64 
14.39 
14.33 
47.97 
28.51 
17.64 

8.97 
13.99 

9.24 
30.45 
28.63 
16.14 
13.38 


Total  number  of  cases  of  typhoid  fever  reported  in  the  above-mentioned 
cities  in  1896  and  1897 . 15,675 

Total  number  of  deaths  among  the  cases  reported  in  the  above-mentioned 
cities  in  1896  and  1897  3,659 

Percentage  of  deaths  among  reported  cases  in  the  above-mentioned  cities.     16.96 

What  information  have  we  gained  from  .these  figures?  Are  we  to 
infer  from  them  that  the  death  rate  from  typhoid  fever  in  general 
practice  in  onr  large  cities  is  16.96  per  cent,  while  in  our  hospitals, 
to  which,  as  a  rule,  the  graver  cases  are  sent,  it  is  orAj  9.24  j)er  cent 
and  while  in  the  city  of  Hamburg  it  is  only  8.5  per  cent?  In  our 
opinion  such  inferences  are  not  warranted.  We  are  forced  to  con- 
clude that  in  these  cities  in  which  the  health  regulations  require  phy- 
sicians to  report  all  cases  of  typhoid  fever  a  large  per  cent  of  the  cases 
of  this  disease  are  not  recognized  as  typhoid  fever.  The  army  sur- 
geon has  been  severely  criticised  for  not  recognizing  typhoid  fever. 
What  can  be  said  of  the  average  physician  in  general  practice  in  our 
country!  We  must  call  attention  to  the  similarity  in  two  sets  of  fig- 
ures. Referring  back  to  our  percentage  records  concerning  death 
from  typhoid  fever  in  the  First  and  Third  Army  Corps,  it  will  be  seen 
that  the  percentage  of  deaths  among  recognized  cjjsesof  typhoid  fever 
was  16.65  per  cent;  now  we  have  found  that  in  the  above-mentioned 
cities  the  death  rate  among  recognized  cases  of  tj^phoid  fever  is  16.96 
per  cent.  In  other  words,  the  army  surgeon  did  in  his  military  serv- 
ice just  as  he  was  in  the  habit  of  doing  in  his  civil  practice — that  is, 
he  failed  to  properly  diagnose  the  milder  cases  of  typhoid  fever.  His 
military  record  on  this  ijoint  is  no  worse  and  no  better  than  was  his 
own  record  in  civil  practice,  or  is  the  record  of  physicians  in  some  of 
the  largest  cities  in  the  United  States. 


62 

(Note. — Too  late  for  insertion  in  this  table  we  have  received  the 
f ollo^vino:  figures  concerning  typhoid  fever  in  Xew  York  Cit}^ : 

Xumber  of  cases  of  typhoid  fever  treated  in  New  York  City  dnrmg  the  vear 

mm l..^.  1,004 

Number  of  cases  treated  during  the.  year  1897 1,004 

Number  or  deaths  among  those  treated  in  1896 297 

NuLuber  of  deaths  among  those  treated  in  1897 299 

PercentHge  of  deaths  among  those  treated  in  1896 29.  64 

Percen'age  of  dea  hs  among  those  treated  in  1>'9T 29.  78 

Total  cases  treated  in  New^York  City  in  l-^m  and  1897 2,008 

Total  deaths  amon-;- those  treated  in  1896  and  1897  ..    ._. o'd6 

Percentage  of  deaths  among  those  treated  in  1896  and  1897 29. 71 

Dr.  Roger  S.  Tracy,  register  of  records,  sends  the  following  statement 
with  these  figures: 

"The  'cases  treated'  as  given  al30ve  are  the  cases  reported  to  the 
department  of  health.  It  is  not  prolDable  that  all  cases  are  reported, 
and  there  is  no  way  of  estimating  the  number  that  may  go  unreported. 
Of  course  all  the  deaths  are  included  excepting  the  possible  £ew  cases 
that  maybe  unrecognized  and  go  upon  the  record  under  other  names." 

It  will  be  seen  from  these  figures  that  the  physicians  of  Xew  York 
City  fail  to  recognize  typhoid  fever  to  a  greater  extent  than  did  the 
army  surgeons  at  Chickamauga. ) 

MALARIAL  DISEASES  IN  THE  FIRST   AND  THIRD  ARMY  CORPS. 

As  has  already  been  stated,  all  kinds  of  illnesses  were  diagnosed 
malaria  at  Chickamauga.  We  find  the  most  trivial  cases,  as  well  as 
the  most  serious  ones,  recorded  as  malaria.  The  medical  officers 
apparenth"  went  into  the  southern  camps  believing  that  they  would 
meet  with  this  disease  most  frequently,  and  if  we  accept  their 
recorded  diagnoses  their  expectations  were  certainly  fully  realized. 
It  will  be  interesting  for  us  to  make  an  inquiry  concerning  the  actual 
prevalence  of  malaria  among  these  troops.  In  the  first  place,  it  is 
worthy  of  note  that  in  the  regimental  records  themselves  there  is 
e\i.dence  that  malaria  was  not  a  prevalent  disease  at  Chickamauga 
Park.  This  e\idence  is  furnished  b}'  such  illtistrations  as  the  follow- 
ing: The  Second  Brigade  of  the  Second  Division  of  the  First  Army 
Corps  consisted  of  the  One  hundred  and  fifty-eighth  Indiana,  the  Sixth 
Ohio,  and  the  First  West  Virginia.  These  regiments  were  encamped 
side  by  side.  From  the  regimental  sick  reports  it  appears  that  malaria 
prevailed  in  the  Indiana  regiment  from  3Iay  throughout  the  summer; 
there  were  no  cases  in  the  Ohio  regiment  in  3Iay,  3  in  .June,  11  in 
.July,  103  in  August,  and  203  in  September;  in  the  First  West  Vir- 
ginia Regiment  the  diagnosis  of  malaria  does  not  appear  on  the  regi- 
mental records  until  August,  when  108  cases  are  reported.  That 
there  should  have  been  malaria  in  the  Indiana  regiment  in  ^lay  and 
not  a  case  in  either  of  the  other  regiments  in  the  same  brigade  is 
not  probable ;  and  that  it  could  have  required  two  months  for  this 
disease,  had  Chickamauga  been  the  fearfully  malarious  place  it  is 
said  by  some  to  be,  progressing  slowh*  through  the  Ohio  regiment,  to 
reach  the  West  Virginia  regiment  is  not  in  accord  with  any  known 


63 

epidemiological  facts  concerning  this  disease.  We  think  that  snch 
unequal  distribution  of  the  disease  as  shown  by  the  above-mentioned 
records  is  proof  quite  convincing  that  malaria  was  not  widely  preva- 
lent among  the  troops  at  Chickamauga.  We  have  already  seen  that 
practically  all  of  the  prolonged  malarias  were  actually  cases  of  typhoid 
fever.  Many  of  the  temporary  illnesses  diagnosed  as  malaria  may 
actually  have  been  due  to  the  Plasmodium,  but  how  manj^  were  due 
to  this  cause  we  can  not  positively  state. 

It  is  to  be  regretted  that  qualified  men  properly  equipped  were  not 
placed  earlier  at  all  the  national  encampments,  in  order  to  make  sci- 
entific diagnoses  of  malarial  and  typhoid  fever.  Scientific  medicine 
would  have  been  greatly  enriched  had  this  been  done.  As  soon  as 
we  began  the  inspection  of  camps  and  hospitals  w^e  saw  that  it  was 
absolutel}^  necessary  to  provide  for  scientific  diagnoses.  In  the  divi- 
sion hospitals  we  found  that  most  of  the  febrile  cases  were  diagnosed 
as  malaria.  We  believed  that  they  were  typhoid  fever,  but  it  seemed 
presumptuous  in  us  to  set  our  opinion  above  that  of  the  very  compe- 
tent medical  officers  in  attendance.  We  therefore  asked  the  Surgeon- 
General  that  he  should  send  competent  men,  properly  equipped  for 
making  blood  examinations  for  the  malarial  Plasmodium  and  the 
Widal  test  to  each  of  the  large  camps.  The  Surgeon-General  acted 
promptly  on  this  suggestion,  and  we  are  therefore  able  to  give  some 
scientific  information  concerning  the  actual  prevalence  of  malaria. 

At  Sternberg  Hospital,  Chickamauga  Park,  Maj.  R.  Emmett  Giffen, 
surgeon  in  command  of  the  hospital,  established  a  bacteriological 
laboratory  and  placed  the  same  under  the  charge  of  Acting  Asst. 
Surg.  Charles  F.  Craig.  The  following  is  Dr.  Craig's  report  of  the 
work  done  in  this  laboratory: 

REPORT  OF  THE  BACTERIOLOGICAL  LA.BORATORY  TO  NOVEMBER  1,  1898,  STERN- 
BERG UNITED  STATES  GENERAL  HOSPITAL,  CHICKAMAUGA  PARK,  GEORGIA. 

Maj.  R.  ElIMETT  GiFFIX, 

Chief  Surgeon,  U.  S.  V.,  Commanding  Hosjyiial. 

Sir:  1  have  the  honor  to  submit  to  you  the  following  report  regarding  the  work 
of  the  bacteriological  laboratory  up  to  the  present  date. 

As  it  was  your  intention  in  establishing  the  laboratory  to  aid  in  the  scientific 
study  of  the  cases  treated  in  the  hospital  and  to  investigate  certain  questions  con- 
cerning the  sanitary  condition  in  Chickamauga.  I  have  endeavored  to  follow  your 
suggestions  and  orders  as  closely  as  possible. 

1  have  had  associated  with  me  for  a  -hort  time  Acting  Asst.  Surg.  George  Dock, 
of  Ann  Arbor,  Mich.,  a  most  competent  and  acknowledged  authority  upon  the 
fevers  of  the  South,  especially  malaria,  and  I  have  also  been  ably  aided  by  Dr. 
James  Jobling.  whom  you  detailed  to  me  as  laboratory  assistant. 

The  ^^'ork  in  the  laboratory  has  been  divided  as  follows: 

(a)  The  study  of  typhoid-fever  cases,  includ:ng  post-mortem  examinations  and 
the  use  of  Widai's  test;  (b)  the  examination  of  the  blood  of  suspected  cases  for  the 
Plasmodium  malarite;  (c)  the  bacteriological  analysis  of  water;  (cZ)  the  chemical 
and  microscopical  examination  of  urine,  including  the  diazo-reaction;  (e)  the 
study  of  the  blood  of  typhoid  cases;  (/)  the  stady  of  cases  of  special  interest. 


64 

(a)  There  have  been  ten  post-mortem  examinations  made  of  subjects  dead  of 
typhoid  fever,  ail  of  which  demonstrated  the  pathological  changes  usually  found 
in  that  disease.  I  have  made  several  preparations  illustrating  very  perfectly  the 
changes  occur  ing  in  the  in  estine,  showing  swelling,  infiltration,  ulceration,  and 
perforation  of  Peyers  patches,  and  swell.ng  of  the  solitary  glands. 

Of  special  interest  have  been  the  results  obtained  by  Widal's  serum  test  in  the 
typhoid  cases  in  the  hospital.  I  have  examined  to  date  31.5  cases,  using  the  Widal 
test,  with  the  following  results: 

Of  the  315  cases,  208  were  diagnosed  as  typhoid  fever,  5  as  malaria,  13  as  ques-- 
tionable  typhoid,  20  as  measles,  1  as  typho  malaria,  1  as  simple  fever,  1  as  myal- 
gia, 2  as  pneumonia,  1  as  cystitis,  1  as  tuberculosis,  1  as  questionable  tiTberculosis. 
1  as  thermic  fever,  2  as  dysentery,  and  58  had  no  diagnosis. 

Of  the  208  cases  diagnosed  as  typhoid,  205  cases  reacted  to  Widal's  test,  while  3 
did  not;  the  latter  cases,  with  the  exception  of  one,  have  since  proven  not  to  be 
typhoid,  while  the' one  is  still  in  doubt. 

Of  the  5  cases  diagnosed  malaria,  2  reacted  to  the  test  and  were  undoubtedly 
typhoid,  while  3  did  not  react. 

Of  the  20  cases  diagnosed  as  measles,  not  one  reacted  to  the  test. 

Of  the  13  cases  diagnosed  questionable  typhoid,  7  gave  reaction,  while  6  gave 
no  reaction. 

One  case  diagnosed  "  typho  malaria"  gave  a  very  marked  reaction,  and  exami- 
tion  of  the  blood  demonstrated  that  no  plasmodia  were  present.  This  case  was 
undoubtedly  a  straight  typhoid. 

One  case  diagnosed  myalgia  gave  no  reaction. 

Two  cases  diagnosed  dysentery  reacted  and  proved  to  be  typhoid. 

One  case  diagnosed  tuberculosis  gave  no  reaction. 

One  case  diagnosed  tuberculosis  gave  reaction  and  proved  to  be  typhoid. 

One  case  diagnosed  cystitis  gave  no  reaction. 

Two  cases  diagnosed  pneumonia  gave  no  reaction. 

One  case  diagnosed  therinic  fever  gave  no  reaction. 

One  case  diagnosed  "  simple  fever  "  gave  a  reaction  and  proved  to  be  typhoid. 

Of  the  58  cases  having  no  diagnosis,  30  reacted  to  the  test,  while  28  did  not.  Of 
the  28  which  did  not,  10  were  too  recent  for  the  reaction  to  appear. 

I  have  divided  the  reactions  to  the  test  as  follows: 

1.  Character  of  reaction:  Marked.  150  cases:  medium,  58  cases;  slight,  27  cases. 

2.  Time  of  reaction:  Immediate,  95  cases;  in  five  minutes,  64  cases:  in  ten  min- 
utes, 38  cases;  in  fifteen  minutes, "25  cases;  in  t\yenty  minutes,  8  cases;  in  twenty- 
five  m^inutes,  6  cases. 

The  slowest  reaction  observed  was  complete  within  twenty -five  minutes. 

The  earliest  reaction  was  obtained  upon  the  fourth  day  of  the  disease,  the  latest 
upon  the  sixtieth  day.  There  were  5  reactions  at  the  fourth  day,  8  at  the  fifth.  10 
at  the  sixth.  5  at  the  seventh,  the  remaining  reactions  ranging  from  the  eighth  to 
the  fortieth  dav  of  the  disease. 

From  the  foregoing  report  it  will  be  seen  that  the  Widal  serum  test  proved  the 
diagnosis  of  typhoid  fever  in  99  per  cent  of  the  cases  so  diagnosed,  there  being 
1  case  still  in  doubt,  and  it  further  proved  that  at  least  80  per  cent  of  the  sick 
in  this  hospital  were  suffering  from  typhoid  fever.  In  cases. other  than  typhoid 
the  lest  gave  a  negative  result  of  100  per  cent. 

The  Widal  test  has  thus  proved  its  great  utility,  and  the  results  obtained  in  this 
laboratory  conclus  vely  show  its  great  value  as  a  diagnostic  measure  and  its 
therapeutic  use  as  indicating  the  treatment  to  be  pursued  in  doubtful  cases. 
Many  of  the  reactions  were  very  marked  and  demonstrated  beautifully  the  inhibi- 
tory action  of  typhoid  blood  serum  upon  the  movements  of  the  bacillus  of  typhoid. 

The  cultures  used  in  making  the  ti-sts  were  twenty-four-hour  cultures,  obtained 
originally  from  pure  cultures  sent  to  the  laboratory  from  the  laboratory  of  the 


65 

United  States  Army  Medical  Museum  and  the  laboratory  of   Johns   Hopkins 
University. 

(b)  The  examination  of  suspected  cases  for  the  malarial  Plasmodium  has  resulted 
in  the  demonstration  of  only  4  cases  of  malaria  in  this  hospital  since  the  laboratory 
was  established. 

Acting  Asst.  Surg.  George  Dock,  during  his  work  in  this  laboratory,  demon- 
strated the  tertian  organism  in  1  case,  and  since  his  departure  I  have  found  the 
quartan  in  1  case,  and  the  Eestivo-autumnal  in  2  cases. 

(c)  The  bacteriological  analysis  of  the  water  of  Chickamauga  Park  has  been 
carefully  and  steadily  carried  on,  and  I  have  already  submitted  to  you  three  reports 
ui3on  the  examination  of  certain  waters  which  you  wished  analyzed. 

The  results  may  be  summed  up  as  follows: 

Samples  of  water  from  the  following  localities  have  been  examined: 

Chickamauga  Creek,  Intake  spring;  on  Cave  spring  branch  of  creek,  north  well; 
first  well  south  of  north  well;  second  well  south  of  north  well;  Upper  Ellis  spring; 
Lower  Ellis  spring;  MuUis  spring;  Kelly  House  well;  Kelly  field  well;  Broth erton 
well;  the  wells  upon  Snodgrass  Hill  road  and  Dyer  House  well;  Blue  spring,  and 
Cloud  s])ring. 

The  following  water  was  found  pure  and  fitted  for  domestic  use:  From  Chicka- 
maugua  Creek,  if  filtered;  north  well,  second  well  south  of  north  well,  Upper  Ellis 
spring,  Kelly  House  well,  Kelly  field  well.  Dyer  House  well,  second  well  on  Snod- 
grass Hill  road,  Blue  spring,  and  Cloud  spring. 

The  water  from  the  following  localities  was  condemned:  Spring  on  Cave  spring 
branch  of  Chickamauga  Creek  (contained  B.  coli.  communis);  first  well  south  of 
north  well,  on  Lafayette  road  (contained  proteus  vulgaris);  Lower  Ellis  spring 
(too  much  bacterial  life) ;  MuUis  spring  (too  much  bacterial  life) ;  Brotherton  well 
(too  much  bacterial  life). 

I  have  been  unable  to  demonstrate  the  typhoid  bacillus  in  any  of  the  water 
examined. 

(d)  The  work  in  urinary  analysis  has  been  divided  into  chemical,  microscopical, 
and  bacteriological. 

The  chemical  examinations  have  been  conducted  by  Dr.  Jobling,  about  200  sam- 
ples having  been  analyzed. 

The  microscopical  and  bacteriological  examinations,  conducted  by  myself,  have 
thus  far  shown  nothing  of  special  interest,  unless  it  be  the  occurrence  in  the  urine 
of  typhoid  cases  of  numerous  bacteria,  chiefly  micrococci. 

The  diazo-reaction  has  been  applied  in  a  large  number  of  cases,  and,  while  always 
present  in  typhoid,  it  also  occurred  in  other  diseases. 

(e)  I  have  examined,  bacteriologically,  the  blood  of  12  cases  of  typhoid  fever,  and 
will  submit  to  you  shortly  a  special  report  concerning  the  conclusions  arrived  at. 

(/)  I  have  paid  special  attention  to  the  study  of  individual  cases,  presenting 
special  symptoms,  and  especially  to  those  cases  simulating  the  so-called  "typho- 
malarial "'  fever  of  older  writers.  Within  the  last  month  I  have  found  2  cases  of 
undoubted  double  infection,  the  Plasmodium  malariae  and  the  typhoid  bacillus 
being  present  at  the  same  time  in  the  same  case.  These  cases  are  of  great  inter- 
est, and  I  will  submit  to  you  a  special  report  concerning  them,  together  with 
charts,  etc. 

The  laboratory  has  been  in  operation  only  about  five  weeks,  but  its  value  has 
been  proven,  from  a  practical  as  well  as  a  scientific  standpoint,  to  the  hospital,  and 
has  demonstrated  the  wisdom  of  your  course  in  establishing  it. 

Had  laboratory  facilities  been  possible  or  available  when  the  troops  were  first 
sent  to  the  park,  much  of  the  sickness  and  distress  which  followed  might  have 
been  prevented, 

7273 5 


66 

A  special  report  regarding  the  relation  of  flies  and  other  insects  to  the  spread  of 
typhoid  fever  will  be  submitted  to  you  as  soon  as  it  can  be  prepared. 
Respectfully  submitted. 

Chas.  F.  Craig, 
Acting  Assistant  Surgeon,  U.  S.  A. 

The  following  is  a  copy  of  the  report  of  Professor  Dock: 

REPORT   ON   EXAMINATION   OF  BLOOD   IN    UNITED   STATES   ARMY    HOSPITALS, 
SEPTEMBER,  1898,  BY  GEORGE  DOCK,  M.  D.,  OF  ANN  ARBOR,  MICH. 

On  September  7  I  received  orders  to  proceed  to  Sternberg  Hospital,  Chicka- 
mauga,  Ga.  Arriving  Sep^"ember  9, 1  received  every  aid  and  encouragement  from 
the  chief  surgeon,  Maj.  R.  E.  Griffin.  I  found  that  Acting  Asst.  Surg.  C.  F.  Craig 
had  fitted  up  a  laboratory  for  bacteriological  investigations,  and  must  here 
express  my  thanks  for  the  courtesy  with  which  he  put  at  my  disposal  all  the  appa- 
ratus and  a  place  for  working.  I  therefore  lost  no  time  in  beginning  my  investi- 
gations. I  soon  discovered  that  many  cases  were  diagnosed  ' '  malaria  "  without 
any  obvious  reason  so  far  as  the  well-known  clinical  peculiarities  of  malarial  dis- 
ease are  concerned  and  without  any  attempt  at  differential  diagnosis  between 
malaria  and  typhoid  fever.  In  some  wards  many  cases  were  diagnosed  raalarial, 
in  others  none  I  went  through  one  of  these  wards  with  the  acting  assistant  sur- 
geon in  charge,  but  the  "dozens  of  cases  of  typical  malaria'"  he  said  he  had  were 
reduced  to  one  doubtful  case  on  examination  of  the  history,  temperature  chart, 
and  patient.  Microscopic  examination  of  the  blood  showed  no  parasites,  and  the 
Widal  test  was  quickly  positive.  In  this  way  a  number  of  cases  thought  to  be 
malarial  were  examined.  In  all,  the  blood  was  free  from  parasites;  the  Widal  test 
positive.  Having  made  all  the  examinations  requested  by  the  surgeons,  I  began 
a  personal  examination  of  the  patients,  going  through  each  ward  in  order,  exam- 
ining all  the  fever  cases,  and  making  examinations  of  the  fresh  blood  in  all  cases 
that  seemed  doubtful  or  otherwise  important.  In  most  of  the  cases  quinine  had 
been  given,  usually  in  large  doses,  up  to  40  grains  a  day.  This  would  have  inter- 
fered with  the  examination  in  general,  but  inasmuch  as  the  symptoms  continued, 
the  diagnoses  were  in  some  cases  "continued  malaria,"  " typho-malaria,"  or 
"mixed  infection,"'  and  the  surgeons  in  charge  still  adhered  to  the  malarial  char- 
acter. Many  examinations  were  made  in  such  cases,  always  with  negative  results. 
Out  of  65  cases  in  which  the  blood  was  examined'  5  had  had  no  quinine  at  all,  and 
5  more  had  had  none  for  several  days  before  the  examinations  were  begun.  Among 
the  former  I  included  a  case  that  had  had  one  dose  (0.6  gram)  of  quinine  a  few 
hours  before  the  examination,  and  the  only  case  in  which  parasites  were  found. 
This  case  was  important  in  a  number  of  ways.     The  notes  are  as  follows: 

Private  Mclntyre,  Company  H,  Second  Arkansas,  ill  five  days  with  fever,  slight 
chills,  ' '  pain  all  over , "'  no  nausea  or  vomiting.  The  bowels  have  been  constipated. 
The  tongue  moderately  large,  the  edge  and' tip  rather  red,  the  dorsum  moist,  with 
a  thin  white  coat.  The  abdomen  is  retracted;  pain  in  the  epigastrium;  there  are 
no  spots.  The  spleen  can  be  easily  felt  an  inch  below  the  margin  of  the  ribs;  the 
edge  is  rounded  and  rather  soft.  The  temperature  on  admission  was  103.5^;  it 
rose  the  same  day  to  104.3  ;  fell  during  the  night  to  101.5";  rose  again  to  104.2°, 


'The  comparatively  small  number  of  cases  examined  depends  partly  on  the  time 

spent  in  selecting  promising  cases  out  of  a  large  number,  often  without  tempera- 
ture charts  or  histories,  but  more  especially  on  the  fact  that  in  cases  with  nega- 
tive results  the  examination  is  necessarily  prolonged  much  beyond  the  time  usually 
necessary  to  find  germs  in  a  positive  case.  In  all  examinations  at  least  two  good 
preparations  were  examined,  and  in  some  cases  as  many  as  ten  examinations  at 
different  times. 


67 

remainiug  there  for  several  hours;  then  fell  to  99.5' ;  rose  soon  after  to  99. 8",  where 
it  remained  until  next  day,  the  fourth  after  admission.  It  then  rose  from  about 
8  a.  m.  and  reached  105.3'  at  4  p.  m.  In  the  afternoon  there  was  a  slight  chill. 
The  temperature  fell  slowly  without  sweating.  The  written  diagnosis  was  typhoid 
fever.  I  saw  the  patient  at  9.30  a.  m.  of  this  day,  and  being  struck  by  the  large 
size  of  the  spleen,  unusual  at  so  early  a  stage  in  typhoid  fever,  examined  the  Ijlood. 
I  must  say  that  the  appearance  of  the  patient  was  not  unlike  that  of  one  in 
the  early  stage  of  typhoid  fever.  The  temperature  was  100.4.  I  found  large 
numbers  of  parasites,  almost  every  field  (one-twelfth  inch  oil  immersion)  con- 
taining one. 

Most  of  them  were  in  the  small  amoeboid  stage,  from  one-fourth  to  one- third 
the  diameter  of  the  red  corpuscles,  and  with  fine  pigment  grains.  There  were  also 
a  few  parasites  in  a  more  advanced  stage,  almost  filling  the  red  cells,  but  without 
any  signs  of  segmentation.  The  indications  were  that  the  patient  had  a  double 
tertian  infection,  with  one  generation  not  numerous  enough,  in  all  probability,  to 
produce  a  marked  paroxysm.  Soon  after  the  examination  the  patient  received  a 
second  dose  of  0.6  gram  of  quinine,  and  the  temperature  fell  to  98.5  at  noon. 
Not  knowing  about  the  quinine  at  first,  I  was  surprised  to  find  the  parasites  dis- 
appearing about  an  hour  after  their  discovery,  and  those  present  were  in  very 
slow  motion.  The  temperature  rose  to  100.4%  then  fell  during  the  night  to  98.5°, 
and  remained  below  normal  up  to  the  time  the  patient  was  discharged  ten  days 
later.  Parasites  were  found  for  two  days  after  defervescence.  They  were  rare 
the  last  time  they  were  found  and  almost  motionless.  The  subjective  sensations 
improved  with  the  fall  of  the  temperature,  and  the  patient  remained  well,  having 
taken  in  all  1.2  grams  of  quinine  (18.5  grains).  (The  patient  said  he  had  chills  in 
Arkansas  in  the  spring] . 

I  have  described  this  case  rather  fully  because  it  seems  of  considerable  impor- 
tance in  more  than  one  respect.  In  the  first  place,  it  shows  how  a  double  tertian 
malarial  infection  may  easily  simulate  typhoid  for  a  short  time.  (It  seems  worth 
noting  that  the  surgeon  in  charge,  Acting  Assistant  Surgeon  Pinckney,  is  familiar 
with  malarial  fever  in  Charleston.  S.  C).  More  important  is  the  fact  that  not- 
withstanding the  fjeculiarity  mentioned,  a  moderate  dose  of  quinine  at  once  cut 
the  disease  short,  although,  as  is  always  the  case,  the  organisms  persisted  for  a 
short  time  after  complete  defervescence.  From  this  fact  and  the  ease  with  which 
recovery  followed,  it  is  not  probable  that  the  large  number  of  cases  diagnosed 
••  malaria  ■■  were  malarial  alone,  since  almost  all  of  them  were  treated  with  quinine, 
usually  in  larger  doses  than  in  this  case.  Many  of  them  had  from  1.5  to  2.5  grams 
daily  for  periods  up  to  three  weeks,  without  any  notable  effect  on  the  tempera- 
ture. On  the  other  hand,  it  is  quite  probable  a  few  cases  of  fever  that  appear  in 
the  reports  were  really  of  malarial  nature.  In  a  number  of  cases  I  obtained  his- 
tories from  men  that  seemed  to  have  been  malarial.  But  these  rapidly  recovered 
under  the  inevitable  quinine.  As  a  rule  these  patients  were  treated  in  quarters 
or  in  regimental  hospitals,  so  that  no  charts  were  kept.  I  was  unable  to  see  any 
of  these  cases  soon  after  defervescence  while  at  Sternberg  Hospital,  but  was  more 
fortunate  at  Camp  Meade. 

The  intensity  of  malarial  infection  in  a  locality  like  Chickamauga  Park  in  sum- 
mer can  be  estimated  in  general  by  the  number  of  cases  of  simple  intermittent 
fever  observed.  I  know  of  no  reliable  statistics  in  the  camp,  but  from  mj-  own 
investigations  think  the  number  must  have  been  very  small.  I  am  confirmed  in 
my  belief  by  information  kindly  furnished  by  Maj.  F.  P.  Robinson,  surgeon  of 
the  Sixth  U.  S.  Volunteers,  who  told  me  that  in  the  two  months  his  regiment 
was  encamped  in  the  park  he  had  not  had  more  than  6  cases  of  simple  intermittent 
fever. 

While  the  evidence  for  frequent  malarial  infection  is  therefore  lacking,  the  clin- 
ical features  of  a  very  large  proportion  of  the  fever  cases  were  those  of  typhoid 


68 

fever,  not  differing  on  the  whole  from  that  disease  as  seen  in  other  parts  of  the 
country,  as  well  as  in  Europe.  In  some  cases  the  skin  and  mucous  membranes 
showed  evidences  of  lack  of  care  (bedsore,  multiple  abscess,  ulcers  of  the  mouth). 
Some  cases  showed  marked  depression,  sometimes  perhaps  due  to  the  large  doses 
of  quinine  or  to  other  antipyretics,  or  to  overdoses  of  whisky  (half  ounce  every 
two  hours  from  the  time  of  admission) .  The  course  of  the  temperature  in  most 
cases  was  characteristic;  the  enlargement  of  the  spleen  was  evident  in  many. 
The  roseolar  eruption  was  often  present,  but  sometimes  masked  by  innumerable 
spots  due  to  flies  and  other  insects.  Blue  spots  I  saw  in  three  cases,  in  all  of  which 
lice  had  apparently  been  present,  but  were  not  when  I  saw  the  patients.  The 
stools  in  most  cases  were  quite  characteristic.  In  all  the  blood  examinations 
on  uncomplicated  cases  I  made  the  leucocytes  were  diminished,  or  at  least  not 
increased.  The  Widal  test  was  made  in  a  number  of  cases  by  myself,  confirming 
or  clearing  up  the  diagnosis.  This  test  was  made  on  a  most  extensive  scale  by 
Acting  Assistant  Surgeon  Craig,  who  will  report  his  results. 

In  two  cases  I  made  autopsies  on  the  bodies  of  patients  dead  of  typhoid  fever. 
I  append  brief  notes: 

Case  i.— Charles  Kirk,  musician.  Company  B,  Fourteenth  New  York,  18  years 
old.  Admitted  to  Sternberg  Hospital  September  5,  in  ward  of  Acting  Assistant 
Surgeon  Barnhart.  Patient  felt  ill  one  or  two  days  before  admission.  Diagnosis: 
Typhoid  fever.  Temperature,  moderately  high;  marked  delirium;  for  three  days 
before  death  vomiting  and  involuntary  discharge  of  watery  stools.  Died  Septem- 
ber 15,  1898.  Examined  one  hour  after  death.  No  rigor  mortis;  slight  lividity  on 
the  back;  face  dusky;  muscles  dry  and  dark  red;  no  Zenker's  degeneration.  Lungs 
collapsed,  slight  hypostatic  congestion  of  the  left  lower  lobe;  rest  of  lungs  anemic; 
free  from  lesions.  Pleurae  not  diseased.  ■  Pericardium  normal.  Heart  distended 
with  fluid,  dark  blood;  muscles  firm  and  of  normal  appearance;  valves  normal. 
Spleen  very  large,  estimated  weight  IJ  pounds;  capsule  smooth,  section  dark  red, 
anemic;  Malpighian  bodies  distinct.  Kidneys  slightlj^  enlarged,  pale;  cortex 
wide;  parenchyma  cloudy;  Malpighian  bodies  prominent;  pyramids  anemic. 
Ureters  negative.  Bladder  empty.  The  serosa  of  the  ileum  is  red  for  about  3 
feet  above  the  valve.  The  appendix  is  red  and  swollen.  The  mesenteric  glands 
are  enlarged,  red;  those  corresponding  to  the  lower  end  of  the  ileum  reaching  the 
size  of  pigeon  eggs.  The  mucous  membrane  of  the  stomach  is  red  andecchymosed. 
The  ileum  shows  great  swelling  of  the  mucous  membrane,  folds  being  present  all 
the  way  to  the  valve.  The  lower  5  feet  of  the  gut  show  swelling  of  the  solitary 
glands  and  Peyer's  patches,  the  former  reaching  a  diameter  of  8  mm.  Most  of  the 
lymphoid  tissue  is  in  the  stage  of  inedulary  infiltration,  but  a  few  solitary  nodules 
show  superficial  necrosis.  The  mucosa  of  the  valve,  the  cascum,  and  appendix  are 
red  and  swollen.  Two  of  the  largest  mesenteric  glands  contain  necrotic  foci. 
The  liver  is  large,  the  surface  rough,  section  pale,  acini  distinct;  the  consistency 
is  tough;  the  capsule  of  Glisson  increased.  There  are  a  few  small  grey  areas  on 
the  section.  Gall  bladder  full,  not  altered;  the  lymph  glands  at  the  neck  are 
large  and  red. 

Microscopic  examination  of  the  spleen  pulp  showed  the  absence  of  malarial  pig- 
ment. Eberth's  bacilli  were  cultivated  from  the  spleen  by  Acting  Assistant  Sur- 
geon Craig. 

Case  ^.—Private  Pudil,  Company  H,  Thirty-first  Michigan.  Acting  Assistant 
Surgeon  N  orris.  Patient  came  from  Knoxville  to  visit  relatives.  While  in  ward 
was  noticed  by  surgeon  in  charge,  who  found  a  temperature  of  104°  F.  Patient 
was  sick  two  weeks  after  that,  having  fever  rarely  less  than  103.5'  F.,  anxious  and 
delirious  all  the  time.  September  11  there  was  a  slight  hemorrhage.  September 
15  complained  of  pain  in  the  abdomen,  which  was  found  rigid.  Diagnosis  of  per- 
foration and  peritonitis.     Death  September  16. 

•Autopsy  showed  slight  hypostatic  congestion  of  both  lungs;  spleen  enlarged; 


69 

the  lower  end  contained  a  hemorrhagic  infarction  4  cm.  in  diameter.  The  peri- 
toneum is  red,  swollen,  and  rough  all  over,  containing  about  a  quart  of  thin, 
yellow,  watery  fluid  containing  yellow  flakes  of  fibrin,  and  in  the  pelvis  a  small 
amount  of  thin,  yellow  feces.  The  liver  and  spleen  are  also  covered  with  thin 
fibrinous  exudate.  The  serous  surface  of  the  lower  part  of  the  ileum  is  dark  red 
or  violet.  About  a  foot  above  the  caecum  is  a  perforation  3  by  4  mm.  in  diame- 
ter. The  mesenteric  glands  are  moderately  enlarged.  The  mucosa  of  the  ileum 
is  moderately  swollen.  The  Peyer's  patches  and  solitary  glands  in  the  upper  part 
of  the  diseased  area  are  swollen,  but  with  pitted,  or  reticulated,  or  gray  surfaces. 
The  Peyer"s  patches  in  the  lower  3  feet  of  the  ileum  are  ulcerated;  some  to  the 
inner,  some  to  the  outer  muscular  coat,  one,  2  cm.  in  diameter,  to  the  serosa  in  a 
small  part,  without  perforating.  The  perforating  ulcer  is  2.5  cm.  in  diameter. 
Some  of  the  ulcers  have  thickened  edges,  some  not;  all  are  clean,  and  a  large  one 
just  above  the  valve  is  covered  with  healthy  granulations.  The  mucous  mem- 
brane of  the  caecum  is  swollen  and  of  dark  violet  color.  The  left  kidney  contains 
an  antemic  infarct  1  inch  in  diameter.  The  pelvis  is  red,  swollen,  and  contains 
thin  opaque  mucous  fluid.     Bladder  unaltered. 

Microscopic  examination  of  the  splenic  pulp  shows  absence  of  malarial  pigment. 

In  Knoxville  I  examined  the  blood  of  14  patients  diagnosed  as  having  malarial 
or  " typho-malarial  fever"  In  1  case  the  diagnosis  was  "malarial  jaundice," 
though  the  history  pointed  rather  to  acute  indigestion,  and  there  had  been  no 
actual  icterus.  Quinine  had  been  used  in  all  cases.  The  blood  in  all  was  nega- 
tive, I  saw  a  great  many  cases  diagnosed  malaria  that  were  evidently  typhoid, 
but  all  had  taken  quinine  in  large  doses. 

In  the  division  hospital  I  became  acquainted  with  a  major  and  surgeon  who  had 
been  making  diagnoses  of  malaria  ostensibly  by  the  use  of  the  microscope,  both  at 
Chickamauga  and  later  at  Knoxville.  I  was  convinced  that  he  was  totally  unable 
to  recognize  malarial  parasites.  Experts  need  only  to  be  told,  by  way  of  proof, 
that  in  all  cases  he  found  the  so-called  parasites  in  large  numbers,  usually,  as  he 
said,  in  every  red  corpuscle.  He  demonstrated  his  inability  to  distinguish  between 
red  and  white  corpuscles  in  his  own  blood. 

When  I  arrived  at  Camp  Meade  I  found  comparatively  few  cases  vnth  the  diag- 
nosis of  malaria  in  the  Second  Division  hospital.  Most  of  the  surgeons  claimed 
that  malarial  disease  was  very  rare  there.  I  found  two  wards,  the  so-called 
malarial  wards  (3  and  4),  in  which  a  great  many  cases  had  the  diagnosis  of 
malaria.  I  examined  the  blood  of  many  of  these,  also  of  many  recently  admitted 
men  and  some  suspicious  cases  in  the  other  wards,  to  the  number  of  20,  but  with- 
out finding  any  parasites.  As  the  bacteriological  outfit  was  incomplete,  Widal 
tests  could  not  be  made,  but  out  of  the  so-called  malarial  cases  at  least  two-thirds 
were  evidently  typhoid  in  the  middle  stage,  some  not  yet  definitely  recognizable 
and  some  convalescent.  Some  of  the  other  cases  appeared  to  be  convalescent 
from  malaria  without  typhoid  manifestations. 

In  the  First  Division  hospital  I  was  told  there  were  a  great  many  cases  of 
malaria  and  typho-malarial  fever.  Several  so-called  typical  cases  of  the  latter 
had  no  parasites  and  were  evidently  uncomplicated  cases  of  typhoid  fever.  One 
case  proved  to  be  malaria,  and  is  quite  as  instructive  as  the  positive  case  found  at 
Chickamauga. 

Ca.se  3. — Private  Beyer.  Company  F,  Fifteenth  Pennsylvania,  came  two  weeks 
before  examination  from  Sheridan's  Point,  Va,  Four  days  later  he  began  to  have 
chills,  and  had,  so  far  as  he  knows,  three  chills,  tertian  (?),  He  felt  quite  well 
the  free  days.  The  temperature  had  not  been  taken  often  enough  to  give  the 
type.  There  had  been  a  chill  the  day  before  examination,  and  the  patient  had 
taken  24  grains  of  quinine  in  two  days.  Soon  after  beginning  the  examination  I 
found  an  oi'ganism  almost  filling  a  red  blood  corpuscle,  I  thought  the  patient 
was  nearing  a  paroxism,  but  on  examining  the  preparation  further  I  found  no 


70 

other  parasites  in  two  very  good  covers.  The  temperattire  taken  then  was  98"  F., 
and  the  patient  felt  well.  He  had  no  doubt  recovered  for  the  time  being,  fur- 
nishing another  example  of  the  ease  with  which  such  infections  can  be  broken  vip. 
Like  the  case  previously  described,  he  came  to  camp  already  infected.  As  a  matter 
of  diagnostic  interest  it  may  be  added  that  this  was  the  only  case  among  several 
hundred  with  fever  examined  by  me  with  herpes  on  the  lips. 

To  summarize,  I  found  remarkably  little  evidence  that  malaria  was  prevalent 
in  Sternberg  Hospital,  in  Camp  Meade,  and  in  the  division  hospital  at  Knoxville, 
the  only  cases  found  having  been  imported. 

Malarial  infection  was  probably  more  common  than  the  results  of  my  blood 
examinations  indicate,  but  was  easily  broken  up,  and  malaria  was  an  inconsider- 
able factor  in  the  large  number  of  fever  cases  that  appear  under  various  names 
in  the  hospital  records  of  these  camps. 

I  found  no  evidence  of  combined  typhoid  and  malarial  infection.  Among  so 
large  a  number  of  cases  of  typhoid  fever  in  men  from  all  parts  of  the  country 
some  cases  of  thai  kind  must  have  occurred.  The  examinations  of  experienced 
observers,  and  especially  of  those  who  had  opportunities  for  making  autopsies  in 
the  city  hospitals,  to  which  many  patients  were  sent  with  the  diagnosis  of 
"  malaria,"  will  be  of  great  interest  in  this  connection. 

The  nomenclature  of  fevers  in  the  camps  named  was,  on  the  whole,  irrational 
and  arbitrary. 

George  Dock, 

Ann  Arbor,  Mich.,  October  17,  1898. 

INTESTINAL   DISORDERS  IN   THE    FIRST   AND   THIRD  ARMY 

CORPS. 

Intestinal  disorders  were  very  common  among  these  troops.  It  is 
safe  to  say  that  at  least  two-thirds  of  the  officers  and  men  at  Chick- 
amauga  suffered  more  or  less  from  some  form  of  intestinal  disturb- 
ance. These  intestinal  disturbances  were  recorded  under  different 
names  according  to  the  individual  views  of  the  surgeons  in  charge. 
Gastritis,  gastro-enteritis,  and  enteritis  seemed  to  have  been  favorite 
expressions  under  which  many  regimental  surgeons  recorded  these 
cases.  In  some  regimental  records  the  above-mentioned  terms  appear 
almost  to  the  exclusion  of  the  word  "diarrhea,"  while  in  other  regi- 
ments nearly  all  of  these  cases  were  recognized  as  acute  diarrhea,  which 
certainly  was  the  correct  diagnosis.  We  have  carefully  searched  the 
records  and  fail  to  find  any  evidence  of  the  existence  of  a  case  of 
amoebic  dysentery  among  these  soldiers.  In  fact,  true  dj^sentery  was 
certainly  very  rare.  Most  of  the  cases  of  intestinal  disorder  were 
diarrheas  in  which  the  lower  part  of  the  large  intestine  only  was 
affected.  In  a  few  instances  ulceration  resulted.  In  most  cases  there 
was  no  elevation  of  temperature,  and  the  men  were  excused  from  duty 
for  from  one  to  three  days.  We  are  inclined  to  attribute  the  diarrheas 
to  infection  with  saprophytic  germs  brought  from  the  sinks  and 
deposited  on  the  food  by  flies. 

The  relation  of  the  intestinal  disorders  to  typhoid  fever  is  of  con- 
siderable interest  to  us,  and  we  have  already  gone  somewhat  exten- 
sively into  this  subject  in  the  histories  of  the  Sixth  Ohio  and  the  First 
West  Virginia  regiments.     This  matter  is  of  sufficient  importance  to 


71 

justify  us  in  inquiring  into  it  further.  In  the  first  place  it  should  be 
stated  that  the  regimental  surgeons  followed  no  definite  rules  in  their 
reports  of  intestinal  disorders.  Some  of  them  evidently  recorded 
every  case  reported  to  them,  while  others  made  record  of  only  the 
more  serious  ones. 

In  the  First  Arkansas  Volunteer  Infantry  359  cases  of  diarrhea  are 
recorded.  In  the  same  regiment  there  were  228  cases  of  probable 
typhoid  fever.  Sixty  of  the  individuals  who  had  typhoid  fever  had 
had  some  previous  intestinal  disturbance.  We  have  already  called 
attention  to  the  fact  that  in  many  instances  the  preceding  intestinal 
disorder  was  evidently  a  part  of  the  typhoid  process. 

The  following  cases  from  this  regiment  are  illustrations  of  this 
relation : 

No.  1. — Dysentery  August  15-18;  typhoidfever  August  20;  furloughed  August  21. 
No.  2. — Diarrhea  June  14-16;  typhoid  fever  June  23;  furloughed  August  17. 
No.  3. — Diarrhea  August  2-6;  typhoid  fever  August  14;  furloughed  August  i3. 
No.   4.. — Dysentery  August    5-10;    gastritis,  August    16-18;    continued   fever, 
August  19;  died  September  19. 
No.  5. — Gastritis  June  2-3;  typhoid  fever  June  10. 
No.  6.— Diarrhea  July  7-10;  typhoid  fever  July  31;  died,  August  9. 
No.  7. — Diarrhea  August  10-16;  typhoid  fever  August  20. 
No.  8. — Diarrhea  May  30-31;  dysentery  June  2-3;  typhoid  fever  June  16. 
No.  9. — Diarrhea  August  1-2;  typhoid  fever  August  12. 
No.  10. — Dysentery  July  31  to  August  3;  typhoid  fever  August  16. 
No.  11. — Diarrhea  July  20-31;  typhoid  fever  August  2. 
No.  12. — Diarrhea  June  7-10;  typhoid  fever  July  3. 
No.  13. — Diarrhea  July  28-31;  typhoid  fever  August  15. 
No.  14. — Diarrhea  July  26-27;  typhoid  fever  August  16. 
No.  15. — Diarrhea  July  28-29;  typhoid  fever  August  19. 
No.  16. — Diarrhea  August  29  to  September  2;  typhoid  fever  September  7. 
No.  17. — Diarrhea  July  29  to  August  2;  typhoid  fever  August  15. 
No.  18. — Diarrhea  August  6-12;  typhoid  fever  August  16. 
No.  19. — Diarrhea  July  12-13;  typhoid  fever  August  31. 
No.  20. — Diarrhea  May  30-31;  diarrhea  June  15-18;  typhoid  fever  June  19. 
No,  21. — Diarrhea  June  8-11;  typhoid  fever  June  24. 
No.  22. — Diarrhea  June  6-7;  typhoid  fever  June  12. 
No.  ^5.— Gastritis  August  19-20;  typhoid  fever  August  23. 

It  is  possible  that  in  all  of  these  cases  the  intestinal  disorder  that 
preceded  the  typhoid  fever  occurred  about  the  time  of  the  typhoidal 
infection.  We  are  inclined  to  believe  that  in  many  of  those  instances 
the  infection  was  a  mixed  one  and  that  the  effect  of  this  mixed  infec- 
tion was  a  diarrhea. 

Of  the  228  cases  of  probable  typhoid  fever  in  the  First  Arkansas 
Volunteer  Infantry,  168  had  no  illness,  so  far  as  the  record  shows,  pre- 
ceding the  typhoid  fever;  in  other  words,  73.(38  per  cent  of  the  cases 
of  typhoid  fever  were  not  preceded  by  any  recorded  intestinal  disorder, 
while  26.32  per  cent  of  the  cases  of  typhoid  fever  were  preceded  by 
some  intestinal  disorder.     However,  in  23  out  of  the  60  cases  which 


72 

were  preceded  by  some  intestinal  disorder  the  preceding  intestinal 
disorder  was  probably  due  to  the  tyjjhoid  infection. 

In  the  Fifty-second  Iowa  Volunteer  Infantry  there  are  recorded  691 
cases  of  diarrhea,  and  there  were  in  this  regiment  345  cases  of  prob- 
able typhoid  fever;  99  of  the  cases  of  probable  typhoid  fever  were 
preceded  by  some  recorded  intestinal  disorder.  Of  these  the  follow- 
ing may  be  of  interest: 

No.  1. — Diarrhea  August  13-18;  typhoid  fever  A-ugust  24. 

No.  2. — Diarrhea  August  2-8;  typhoid  fever  August  15. 

No.  3. — Diarrhea  August  14-17;  typhoid  fever  August  18. 

No.  4. — Diarrhea  August  26-30;  typhoid  fever  September  7. 

No.  5. — Diarrhea  August  2-3;  typhoid  fever  August  11. 

No.  6. — Diarrhea  July  9-10;  typhoid  fever  July  25. 

No.  7. — Diarrhea  July  11-13;  typhoid  fever  July  20. 

No.  5.— Diarrhea  August  20-22;  typhoid  fever  August  28. 

No.  9. — Diarrhea  July  31  to  August  4;  typhoid  fever  August  19. 

No.  10 — Diarrhea  August  20-26;  typhoid  fever  August  30. 

No.  11. — Diarrhea  August  13-17;  indigestion  August  18-20;  typhoid  fever 
August  20. 

No.  i;^='.— Diarrhea  August  21-27;  typhoid  fever  August  30. 

No.  13. — Diarrhea  August  4-5;  typhoid  fever  August  16. 

No.  14. — Diarrhea  August  19-20;  typhoid  fever  August  21. 

No.  15. — Diarrhea  July  20-22;  diarrhea  July  24-25;  typhoid  fever  July  29. 

No.  16. — Diarrhea  July  30  to  August  18;  typhoid  fever  August  31. 

No.  17. — Diarrhea  August  20-22:  typhoid  fever  August  24. 

No.  18. — Diarrhea  August  15-19;  typhoid  fever  August  26. 

No.  19. — Diarrhea  July  9-16;  typhoid  fever  August  3. 

No.  20. — Diarrhea  August  19-24;  typhoid  fever  August  30. 

No.  ^1.— Diarrhea  August  11-12;  typhoid  fever  August  13. 

No.  22. — Diarrhea  July  3-4;  diarrhea  July  9-16;  diarrhea  July  28-26;  typhoid 
fever  August  13. 

No.  23. — Diarrhea  August  13-14;  typhoid  fever  August  31. 

No.  ^4.— Diarrhea  July  5-6;  typhoid  fever  July  15. 

We  believe  that  in  these  cases  it  is  more  than  probable  that  the 
preceding  intestinal  disorder  resulted  from  a  mixed  infection,  from 
which  typhoid  fever  developed  later.  The  following  summary  will 
show  the  principal  facts  concerning  the  relation  between  typhoid 
fever  and  intestinal  disorders  in  this  regiment : 

Number  of  cases  of  intestinal  disorder -. -  691 

Number  of  cases  of  probable  typhoid  fever  —  ._- --  —    345 

Number  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 
intestinal  disorder - -  - .   -  - -  -   -  - 246 

Percentage  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 
intestinal  disorder     ..    -- .-     71.30 

Number  of  cases  of  probable  typhoid  fever  in  which  the  preceding  intes- 
tinal disorder  probably  had  some  relation  to  the  subsequent  typhoid 
fever - ..--   24 

In  the  Second  Missouri  Volunteer  Infantry  400  cases  of  intestinal 
disturbance  are  reported,  wliile  the  number  of  probable  typhoids  was 
168;  47  individuals  appear  on  both  of  these  lists.     In  the  following 


73 

cases  a  direct  relation  between  the  preceding  intestinal  disorder  and 
the  typhoid  fever  is  regarded  as  probable : 

No,  1. — Diarrhea  July  1-10;  typhoid  fever  July  14. 

No.  2. — Diarrhea  September  6-7;  typhoid  fever  September  8. 

No.  3. — Diarrhea  June  7-8;  diarrhea,  June  17-20;  typhoid  fever  June  28. 

No.  4. — Diarrhea  August  15-17;  typhoid  fever  August  30. 

No.  5. — Diarrhea  September  2-5;  typhoid  fever  September  8. 

The  following  summary  will  show  the  principal  facts  concerning 
the  relation  between  typhoid  fever  and  intestinal  disorders  in  this 
regiment : 

Number  of  cases  of  intestinal  disorder 400 

Number  of  cases  of  probable  typhoid  fever 168 

Number  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 
intestinal  disorder ..... 121 

Percentage  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 
intestinal  disorder .   ..... 72.02 

Number  of  cases  of  probable  typhoid  fever  in  which  the  preceding  intes- 
tinal disorder  probably  had  some  relation  to  the  subsequent  typhoid  fever .       5 

In  the  Ninth  New  York  Volunteer  Infantry  the  number  of  cases  of 
diarrhea  was  497,  while  the  cases  of  typhoid  fever  numbered  323;  73 
individuals  appear  on  both  of  these  lists.  In  the  following  cases  it  is 
probable  that  the  preceding  intestinal  disorder  had  some  relation  to 
the  typhoid  fever: 

No.  1. — Intestinal  colic  July  30-31;  typhoid  fever  August  21. 

No.  2. — Diarrhea  July  30-31;  typhoid  fever  August  3. 

No.  5.— Gastritis  July  15-20;  typhoid  fever  July  26. 

No.  4' — Diarrhea  July  5-6;  typhoid  fever  July  10. 

No.  5.— Diarrhea  August  21-28;  typhoid  fever  September  10. 

No.  6. — Diarrhea  July  2-5;  typhoid  fever  July  9. 

No.  7. — Diarrhea  August  8-9;  typhoid  fever  August  19. 

No.  8. — Diarrhea  August  12-13;  typhoid  fever  August  30. 

No.  9. — Gastritis  July  30  to  August  1;  typhoid  fever  August  7. 

No.  10. — Dysentery  August  27-29;  typhoid  fever  August  30. 

No.  11. — Diarrhea  June  9-12;  typhoid  fever  June  29. 

No.  12. — Diarrhea  July  2-3;  diarrhea  July  6-8;  typhoid  fever  July  19. 

No.  IS. — Intestinal  colic  June  1-2;  typhoid  fever  June  10. 

No.  i^.— Diarrhea  July  18-29;  typhoid  fever  July  30. 

No.  15. — Gastro-duodenitis  July  1-2;  typhoid  fever  July  28. 

No.  16. — Gastro-enteritis  August  2-8;  typhoid  fever  August  17. 

No.  i7.— Diarrhea  July  29-31;  typhoid  fever  August  4. 

No.  18. — Diarrhea  August  28-30;  typhoid  fever  September  5. 

No.  19. — Indigestion  June  5-6;  typhoid  fever  June  14. 

No.  -ff.— Diarrhea  August  18-20;  typhoid  fever  September  1. 

No.  -?i.— Diarrhea  July  10-11;  typhoid  fever  July  20. 

No.  ^^.— Diarrhea  June  25-26;  typhoid  fever  July  6. 

No.  28. — Diarrhea  August  23-28;  typhoid  fever  September  3. 

No.  24. — Diarrhea  August  13-16;  typhoid  fever  August  20. 

No.  ^5.— Diarrhea  July  16-17;  typhoid  fever  July  18. 

iVo.  ^6'.— Diarrhea  August  22-23;  typhoid  fever  August  24. 

No.  ^7.— Diarrhea  July  25-27;  typhoid  fever  July  30. 

No.  ^<5.— Intestinal  colic  July  12-17;  typhoid  fever  July  18. 


74 

The  following  summary  will  show  the  principal  facts  concerning  the 
relation  between  typhoid  fever  and  intestinal  disorders  in  this  regi- 
ment: 

Number  of  cases  of  intestinal  disorder 497 

Number  of  cases  of  probable  typhoid  fever 333 

Number  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 
intestinal  disorder _ .   .  -    ... 250 

Percentage  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 
intestinal  disorder ..... 77. 39 

Number  of  cases  of  probable  typhoid  fever  in  which  the  preceding  intesti- 
nal disorder  probably  had  some  relation  to  the  subsequent  typhoid  fever.     28 

In  the  Sixty-ninth  New  York  Volunteer  Infantry  the  number  of 
cases  of  recorded  diarrhea  is  less  than  the  number  of  cases  of  probable 
tj^hoid  fever.  This  is  the  only  regiment  in  which  we  found  this  to 
be  the  case.  The  number  of  diarrheas  recorded  amounts  to  205, 
while  there  are  299  cases  of  probable  typhoid  fever;  the  number  of 
individuals  whose  names  are  found  in  both  of  these  lists  is  57.  In 
the  following  cases  there  is  probably  some  relation  between  the  pre- 
ceding intestinal  disorder  and  the  typhoid  fever : 

No.  i.— Diarrhea  June  19-20;  typhoid  fever  July  9. 

No.  ^.— Gastritis  October  2-12;  typhoid  fever  October  16. 

No.  3. — Dysentery  September  20-27;  typhoid  fever  October  1. 

No.  4. — Dysentery  September  19-80;  typhoid  fever  October  11. 

No.  5. — Diarrhea  July  20-24;  typhoid  fever  July  24. 

No.  6. — Gastritis  September  18-18;  typhoid  fever  September  18. 

No.  7. — Dysentery  July  19-24;  typhoid  fever  August  8. 

No.  8. — Dysentery  September  26  to  October  1;  typhoid  fever  October  11. 

No.  9. — Dysentery  July  28-29;  typhoid  fever  August  8. 

No.  10. — Dysentery  August  2-8;  typhoid  fever  August  17. 

No.  11. — Diarrhea  July  17-18;  typhoid  fever  July  20. 

No.  i^.— Diarrhea  July  18-21;  typhoid  fever  July  30. 

No.  13. — Dysentery  October  13-19;  typhoid  fever  October  23. 

The  following  summary  will  show  the  principal  facts  concerning 
the  relation  between  typhoid  fever  and  intestinal  disorders  in  this 
regiment : 

Number  of  cases  of  intestinal  disorder 205 

Number  of  cases  of  probable  typhoid  fever .  .  299 

Number  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 

intestinal  disorder 222 

Percentage  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 

intestinal  disorder .. 74.24 

Number  of  cases  of  probable  typhoid  fever  in  which  the  preceding  intes- 
tinal disorder  probably  had  some  relation  to  the  subsequent  typhoid 
fever 13 

In  the  Eighth  Massachusetts  Volunteer  Infantry  2,250  cases  of 
intestinal  disorder  and  272  cases  of  probable  typhoid  fever  are  recorded ; 
the  names  of  109  individuals  are  common  to  both  of  these  lists.     In 


75 

the  following  cases  the  preceding  intestinal  disorder  is  regarded  as 
having  some  relation  to  the  typhoid  fever: 

No.  1. — Gastro-enteritis  August  20-28;  gastro-enteritis  September  1-13;  diarrhea 
October  11-15;  sent  to  Fort  Thomas  with  typhoid  fever  October  24.  There  can  be 
but  little  doubt  that  this  man  was  convalescing  from  typhoid  fever  vs^hen  sent  to 
Fort  Thomas  and  that  the  initial  date  of  this  disease  should  be  given  as  August  20. 

No.  .?. — Gastro-enteritis  August  30  to  September  1;  typhoid  fever  September  7. 

No.  o.— Diarrhea  August  8-26;  typhoid  fever  September  3. 

No.  Jf. — Gastro-enteritis  September  10-15;  typhoid  fever  September  37. 

No.  5. — Gastro-enteritis  August  31-26;  typhoid  fever  September  7. 

No.  G. — Gastro-enteritis  September  10-17;  typhoid  fever  September  33. 

No.  7. — Diarrhea  August  15-16;  typhoid  fever  August  23. 

No.  S. — Gastro-enteritis  September  9-13;  gastro-enteritis  September  19-32; 
typhoid  fever  September  23. 

No.  9. — Gastro-enteritis  August  37  to  September  1;  typhoid  fever  September  4. 

No.  10. — Diarrhea  Augvist  9-15;  diarrhea  August  30  to  September  4;  typhoid 
fever  September  25. 

No.  11. — Diarrhea  August  10-16;  typhoid  fever  August  17. 

No.  i;.^— Diarrhea  July  16-22;  typhoid  fever  July  23. 

No.  13. — Gastro-enteritis  September  11-13;  gastro-enteritis  September  19-31; 
gastro-enteritis  September  27-30;  typhoid  fever  October  8. 

No.  14. — Gastro-enteritis  September  5-9;  typhoid  fever  September  24. 

No.  15. — Gastro-enteritis  September  8-12;  typhoid  fever  September  20. 

No.  i6\— Gastro-enteritis  September  15-24;  typhoid  fever  October  3. 

No.  17. — Gastro-enteritis  August  9-14;  typhoid  fever  August  30. 

No.  i(9.— Acute  diarrhea  August  9-14;  typhoid  fever  August  19. 

No.  i9.— Gastritis  September  18  to  October  24;  gastritis  October  24  to  November 
4;  typhoid  fever  November  5. 

No.  20. — Gastritis  October  11-13;  gastritis  October  15-20;  typhoid  fever  Novem- 
ber 2. 

No.  21. — Gastritis  September  5-12;  typhoid  fever  September  29. 

No.  22. — Gastritis  September  19-20;  typhoid  fever  September  28. 

No.  23. — Diarrhea  August  26-38;  gastro-enteritis  September  2-17;  gastro-enteritis 
September  19-25;  typhoid  fever  October  8. 

No.  24. — Gastro-enteritis  August  31  to  September  6;  gastro-enteritis  September 
19-25;  typhoid  fever  October  5. 

No.  25. — Gastro-enteritis  September  6-11;  typhoid  fever  September  11. 

No.  26. — Gastro-enteritis  September  30  to  October  2;  typhoid  fever  October  5. 

No.  27. — Gastro-enteritis  September  37-30;  typhoid  fever  October  5. 

No.  28. — Gastro-enteritis  September  10-18;  typhoid  fever  October  8. 

No.  29. — Gastro-enteritis  September  10-15;  typhoid  fever  September  24. 

No.  30. — Gastro-enteritis  August  23-26;  typhoid  fever  September  5. 

No.  31. — Gastro-enteritis  August  26  to  September  1;  gastro-enteritis  September 
9-13;  gastro-enteritis  September  15-30;  typhoid  fever  October  7. 

No.  32. — Diarrhea  August  4-6;  typhoid  fever  August  9. 

No.  33. — Gastro-enteritis  September  14-16;  typhoid  fever  September  16. 

No.  34.. — Gastro-enteritis  September  9-13;  typhoid  fever  September  13. 

No.  35. — Diarrhea  August  11-12;  gastro-enteritis  August  13  to  September  6; 
diarrhea  September  7-8;  diarrhea  September  8-20;  gastro-enteritis  September  37 
to  October  5 ;  convalescing  from  typhoid  fever  November  5. 

No.  36. — Diarrhea  September  7-8;  typhoid  fever  September  14. 

No.  37. — Diarrhea  August  13-16;  typhoid  fever  August  16. 

No.  c?.?.— Diarrhea  August  14-15;  typhoid  fever  August  18. 


76 

No.  39. — Gastritis  August  19-22;  typhoid  fever  August  23. 

No.  40. — Gastro-enteritis  August  28  to  September  5;  gastro-enteritis  September 
5-14;  typhoid  fever  September  29. 

No.  41. — Gastro-enteritis  August  27-28;  typhoid  fever  September  4. 

No.  4'2. — Diarrhea  August  13-14;  gastro-enteritis  August  20  to  September  15; 
typhoid  fever  September  29. 

No.  43. — Gastro-enteritis  August  27-28;  typhoid  fever  September  1. 

No.  44. — Gastro-enteritis  September  6-8;  typhoid  fever  September  8. 

No.  45. — Gastritis  August  27  to  September  2;  typhoid  fever  September  8. 

No.  46. — Gastro-enteritis  September  28  to  October  7;  typhoid  fever  October  7. 

No.  47. — Gastro-enteritis  August  31  to  September  5;  typhoid  fever  September  5. 

No.  48. — Diarrhea  August  9-14;  typhoid  fever  September  6. 

No.  4-9. — Diarrhea  August  9-10;  diarrhea  August  11-18;  typhoid  fever  Septem- 
ber 3. 

No.  5<^;.— Diarrhea  August  19-22;  diarrhea  August  27  to  September  1;  typhoid 
fever  September  4. 

No.  51. — Diarrhea  August  27-28;  typhoid  fever  August  29. 

No.  52. — Diarrhea  August  31  to  September  2;  typhoid  fever  September  2. 

No.  53. — Gastro-enteritis  September  4-12;  typhoid  fever  September  12. 

No.  54. — Gastro-enteritis  August  22-26;  gastro  enteritis  August  30  to  September 
2;  gastro-enteritis  September  4-15;  typhoid  fever  September  15. 

No.  55. — Gastro-enteritis  September  1-18;  typhoid  fever  September  19. 

No.  56. — Gastro-enteritis  September  16-22;  gastro-enteritis  September  27  to 
October  7;  typhoid  fever  October  14. 

No.  57. — Gastro-enteritis  September  21-28;  typhoid  fever  October  11. 

No.  58. — Gastro-enteritis  September  4-11;  typhoid  fever  September  11. 

It  will  be  seen  that  in  many  of  the  above  given  eases  the  XJreceding 
intestinal  disorder  could  not  have  been  other  than  a  part  of  the 
typhoid  fever  itself.  The  following  summary  will  show  the  principal 
facts  concerning  the  relation  between  typhoid  fever  and  intestinal 
disorders  in  this  regiment: 

Number  of  cases  of  intestinal  disorder 2, 250 

Number  of  cases  of  probable  typhoid  fever 272 

Number  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 

intestinal  disorder .  _ 163 

Percentage  of  cases  of  probable  typhoid  fever  not  preceded  by  any 

recorded  intestinal  disorder .  _ . 59. 9 

Number  of  cases  of  probable  typhoid  fever  in  which  the  preceding  intes- 
tinal disorder  probably  had  some  relation  to  the  subsequent  typhoid 
fever .-         58 

In  the  Second  New  York  Volunteer  Infantry  822  cases  of  intestinal 
disorder  and  161  cases  of  probable  typhoid  fever  are  recorded;  the 
names  of  56  individuals  appear  upon  both  of  these  lists.  In  the  fol- 
lowing eases  there  is  most  probably  some  relation  between  the  pre- 
ceding intestinal  disorder  and  the  typhoid  fever: 

No.  1. — Acute  diarrhea  July  12-13;  typhoid  fever  August  4. 
No.  2. — Diarrhea  July  15-17;  typhoid  fever  August  8. 
No.  5.— Diarrhea  August  3-6;  typhoid  fever  August  12. 
No.  4. — Diarrhea  August  1-7;  typhoid  fever  August  20. 
No.  5. — Diarrhea  July  21-22;  typhoid  fever  August  14. 
No.  6. — Indigestion  August  12-14:  typhoid  fever  August  30. 


77 

No.  7. — Diarrhea  July  16-17;  typhoid  fever  August  8. 

No.  8. — Diarrhea  July  9-10;  diarrhea  July  18-19:  typhoid  fever  August  5. 

No.  9. — Indigestion  August  22-34;  typhoid  fever  August  29. 

No.  i6».— Diarrhea  July  20-21;  typhoid  fever  July  26. 

No.  11. — Diarrhea  July  16-17;  diarrhea  July  20-23;  typhoid  fever  July  31. 

No.  12. — Diarrhea  July  28  to  August  2;  typhoid  fever  August  20. 

No.  13. — Diarrhea  July  31  to  August  1;  typhoid  fever  August  15. 

No.  14. — Diarrhea  July  3-9;  typhoid  fever  July  10. 

The  following  summary  will  show  the  principal  facts  concerning 
the  relation  between  typhoid  fever  and  intestinal  disorders  in  this 
regiment : 

Number  of  cases  of  intestinal  disorder , 822 

Number  of  cases  of  probable  typhoid  fever 161- 

Number  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 

intestinal  disorder . 105 

Percentage  of  cases  of  probable  typhoid  fever  not  preceded  by  any  recorded 

intestinal  disorder . . 65. 21 

Number  of  cases  of  probable  typhoid  fever  in  which  the  preceding  intes- 
tinal disorder  probably  had  some  relation  to  the  subsequent  typhoid  fever.     14 

The  relation  of  the  intestinal  disorders  to  typhoid  fever  became 
more  prominent  as  the  season  advanced.  The  intestinal  disorders  of 
May  and  June  very  infrequently  show  any  relation  to  typhoid  fever, 
while  those  of  July  and  August  frequently  show  such  a  relation. 
Apparently  the  diarrheas  of  May  and  June  had  no  protective  influence 
against  subsequent  infection  with  typhoid  fever,  while  there  can  be 
but  little  doubt  that  the  diarrheas  of  July  and  August  did  show  such 
a  protective  influence.  We  have  already  suggested  an  explanation 
for  this  in  our  discussion  of  the  history  of  the  Eighth  New  York. 
Since  writing  that  part  of  the  report,  we  have  gone  minutely  into  the 
history  of  other  regiments,  and  the  opinion  expressed  at  that  place 
has  been  confirmed  by  our  subsequent  studies. 

Our  conclusions  concerning  the  relation  between  intestinal  disorders 
and  typhoid  fever  among  the  troops  of  the  First  and  Third  Army 
Corps  may  be  summarized  as  follows : 

(1)  A  large  proportion  (averaging  at  least  75  per  cent)  of  the  cases 
of  typhoid  fever  were  not  preceded  by  any  intestinal  disorder. 

(2)  In  a  fair  proportion  of  the  cases  of  typhoid  fever  which  were 
preceded  by  some  intestinal  disorder  it  is  more  than  probable  that 
the  preceding  intestinal  disorder  resulted  from  saprophytic  germs 
taken  into  the  body  simultaneously  with  typhoid  germs.  The  effects 
of  the  saprophytic  germs  were  shown  almost  immediately  and  mani- 
fested themselves  in  some  intestinal  disorder,  while  the  effects  of  the 
typhoid  germs  did  not  appear  until  later. 

(3)  We  are  inclined  to  the  opinion  that  in  these  cases  the  difference 
in  time  between  the  appearance  of  the  intestinal  disorder  and  the 
development  of  the  subsequent  typhoid  fever  represents  the  period  of 
incubation  of  the  latter  disease.  If  this  supposition  be  true,  the 
period  of  incubation  varies  from  two  days  to  three  weeks. 


78 

(4j  The  intestinal  disorders  of  May  and  June  very  infrequently  had 
any  relation  to  typhoid  fever. 

(o)  The  intestinal  disorders  of  July  and  August  frequently  gave 
temporary  immunity  against  typhoid  fever. 

•  (6)  Typhoid  fever  was  in  a  large  proportion  of  the  cases  of  that  dis- 
ease, due  to  a  mixed  infection.  It  is  probable  that  in  many  of  the 
cases  in  which  this  mixed  infection,  occurred,  the  diarrhea  induced 
by  the  saprophytic  microorganisms  so  thoroughly  removed  the  specific 
germs  of  typhoid  fever  that  the  individual  did  not  develop  the  latter 
disease  and  did  acquire,  for  the  time  being  at  least,  a  certain  degree 
of  immunity  to  typhoid  fever. 

(7)  We  certainly  are  justified  iu  concluding  that  the  intestinal  dis- 
orders among  these  troops  did  not  predispose  the  individuals  affected 
by  them  to  typhoid  fever. 


CHAPTER  YII. 
TYPHOID  FEVER  IN  THE  SECOND  ARMY  CORPS,  CAMP  ALGER,  VA. 

Site. — This  camp,  which  was  selected  as  a  rendezvous  for  the  Second 
Army  Coi'ps,  commanded  by  Maj.  Gen.  W.  H.  Graham,  U.  S.  Volun- 
teers, is  located  7^  miles  west  of  Washington,  D.  C,  and  about  6|- 
miles  south  of  the  Potomac  River. 

Topography. — We  have  been  unable  to  procure  a  detailed  topo- 
graphical map  of  the  site  of  Camp  Alger.  We  have  been  informed 
by  Lieut.  Col.  James  L.  Lusk,  U.  S.  Volunteers,  chief  engineer.  Second 
Armj^  Corps,  that  preparations  for  a  map  of  this  kind  were  well 
advanced,  but  that  the  want  of  time  and  the  jjress  of  other  duties 
prevented  its  completion. 

The  point  occupied  as  headquarters  is  elevated  408  feet  above  the 
Potomac  River  and  was  the  highest  point  in  the  camp  site.  The 
average  elevation  of  the  regimental  camp  sites  above  the  Potomac 
River  was  about  300  feet. 

The  general  surface  of  the  camj)  site  is  decidedly  undulating,  being 
well  provided  with  open  spaces  for  regimental  or  brigade  encampment 
and  interspersed  with  native  forests. 

By  consulting  the  map  of  this  camp  site  it  will  be  seen  that  it  is 
traversed  by  a  few  small  brooks  and  provided  Avith  a  number  of 
shallow  springs. 

Geological  formation  and  water  supply. — We  are  indebted  to  Lieu- 
tenant-Colonel Lusk,  IT.  S.  Volunteers,  for  valuable  information  con- 
cerning this  camp  site,  and  from  whose  letter  we  quote  the  following: 

The  layer  of  soil  is  quite  thin  and  is  underlaid  by  a  stratum  of  very  impervious 
clay.  *  *  *  This  stratum  of  clay  appears  to  extend  well  down  toward  the 
rock,  being  generally  separated  from  the  latter  by  a  layer  of  fine  sand,  generally 


79 

called  ' '  quicksand  "  by  the  drillers.  With  a  few  exceptions  this  rock,  of  the  gneiss 
family,  is  covered  by  a  layer  of  so-called  ''rotten  rock."  which  grew  harder 
downward. 

Although  at  first  the  shallow  springs  already  referred  to,  and  neigh- 
boring farm  wells  were  depended  npon  as  a  source  of  water  supply,  it 
was  soon  clearly  seen  that  other  means  would  have  to  be  provided  to 
meet  the  urgent  demands  for  a  better  and  purer  suppl}^  of  water.  An 
attempt  had  been  made  to  anticipate  this  want  on  the  part  of  a  few 
regiments  by  ordinary  dug  wells  located  in  their  own  regimental 
camps. 

As  there  were  no  bathing  facilities,  the  men,  in  most  instances,  were 
marched  to  the  small  branches  of  Accotink  Creek,  several  miles  away, 
or  to  the  Potomac  River,  still  more  distant. 

On  May  25,  1898,  the  first  troops  having  arrived  on  May  18,  an  arte- 
sian well  was  completed  in  the  neighborhood  of  the  camp  of  the  Sixth 
Massachusetts  and  the  Eighth  Ohio  regiments.  This  well  supplying 
a  fair  yield  of  soft,  clear,  and  palatable  water,  the  pressure  for  others 
of  the  kind  in  different  parts  of  the  camp  became  very  great. 

A  board  appointed  by  the  War  Department  reported,  on  June  2, 
1898,  in  favor  of  other  artesian  wells  for  each  regiment,  or  a  series  of 
wells  from  which  the  water  could  be  pumped  to  the  regimental  camps. 
The  first  of  these  plans  was  adopted,  and  we  are  informed  that  about 
June  5  additional  drilling  machines  were  sent  to  the  camp  by  the 
Quartermaster's  Department,  and  that  the  sinking  of  the  wells  was 
ordered  to  be  prosecuted  as  rapidl}^  as  possible  until  there  should  be 
one  for  each  regiment.  This  work  was  under  the  immediate  super- 
vision of  the  chief  engineer  of  the  Second  Army  Corps.  By  reference 
to  the  map  of  this  camp  site,  the  date  on  which  these  wells  were  com- 
pleted, as  well  as  their  depth  and  height  above  the  Potomac  River, 
may  be  ascertained. 

We  here  again  quote  from  Lieutenant-Colonel  Lusk's  letter: 

During  the  formative  period  of  the  camp  the  regiments  arrived  in  rapid  succes- 
sion, before  any  corps  headquarters  had  been  established  or  corps  staff  organized. 
Many  thousand  men  were  thus  gotten  into  camp  grounds  of  insufficient  area,  with 
no  water  supply  except  from  a  few  ordinary  dug  wells,  springs,  and  small  streams. 
Tlie  streams  became  at  once  polluted  and  unfit  for  use.  The  few  wells  and 
springs  affording  an  insufficient  supply  even  for  drinking  and  cooking,  relief  was 
sought  by  digging  shallow  wells  or  sinking  driven  wells  of  small  depth,  using 
small  pipe,  both  classes  of  wells  beiUL;-  sunk  in  the  regimental  camps,  or  by  exca- 
vating holes  in  wet  ground  and  forming  so-called  springs.  The  relief  thus 
obtained  was  precarious  so  far  as  concerns  quantity,  as  the  water  was  sure  to  fail 
upon  the  advent  of  dry  weather. 

We  may  state  that  this  demand  for  a  better  water  supply  was  not 
fully  met,  notwithstanding  the  most  energetic  action  on  the  part  of 
the  chief  engineer  officer,  until  about  the  end  of  June. 

General  location  of  regimental  camp  sites. — These  were,  as  a  general 
rule,  well  selected  and  had  good  natural  drainage,  being  situated  on 


80 

knolls,  mostly  cleared,  but  sometimes  on  wooded  hillsides.  In  a 
number  of  instances,  however,  they  Avere  unnecessarily  limited  in 
area. 

Lieut.  Col.  Charles  Smart,  deputy  surgeon-general,  TJ.  S.  Army, 
having  completed  an  inspection  of  Camp  Alger,  Va.,  states,  under 
date  of  July  13,  1898,  at  which  time  a  number  of  the  regiments  had 
already  occupied  their  camp  sites  for  nearly  two  months,  as  follows: 

The  striking  characteristics  of  the  camps  of  the  First  Division  were  overcrowd- 
ing of  tents  on  the  camp  site,  overcrowding  of  men  in  the  tents,  dust,  sun  glare, 
and  fetid  odors.  The  Eighth,  Twelfth,  and  Thirteenth  Pennsylvania  were  packed 
closely  together,  with  scarcely  an  interval  between  the  regiments,  the  company 
streets  hardly  wider  than  the  intervals  between  adjacent  companies  should  have 
been.  Tents  of  the  same  companies  in  contact  with  each  other  on  the  sides  and 
of  adjacent  companies  in  contact  by  the  ends. 

These  regiments  constituted  the  Third  Brigade  of  the  First  Division, 
and  probably  presented  the  worst  overcrowding  to  be  found  among 
any  of  the  brigades  encamped  at  Camp  Alger.  The  condition  of 
affaii-s  in  the  First  Brigade^  First  Division,  was  only  slightly  better, 
except  that  the  Sixty-fifth  ISTew  York  Infantry,  belonging  to  this 
brigade,  had  more  space. 

According  to  Lieutenant-Colonel  Smart,  the  regimental  camps  of  the 
Second  Division  were  generally  more  expanded  than  those  of  the  First 
Division. 

Disposition  of  garbage  and  excreta. — Garbage  was  deposited  in  open 
pits  near  the  kitchen,  and  sinks  were  placed  at  varying  distances 
beyond  the  garbage  cesspools. 

Referring  to  the  regiments  of  the  First  Division,  Lieutenant- Colonel 
Smart  again  says : 

The  kitchens  were  close  up  against  the  company  tents,  with  uncovered  cesspools 
for  Idtchen  slops  and  garbage,  and  the  sinks  were  also  so  close  that  although  some 
care  was  given  to  covering  the  deposits  with  earth,  the  sink  odor  pervaded  the 
company  streets. 

"We  may  state  that  during  the  months  of  June  and  July  this  condi- 
tion of  cesspools  and  sinks  was  common  to  all  the  organizations  brought 
together  at  this  camp  site.  Their  contents  were  left  much  of  the  time 
uncovered,  even  during  the  dry  weather  prevailing  in  June,  and  their 
condition  was  rendered  still  more  intolerable  after  the  advent  of  wet 
weather,  since,  owing  to  the  high  level  of  the  ground  water,  the  con- 
tents of  the  sinks  floated  to  the  surface,  and  could  not  be  covered 
without  filling  in  the  pits. 

Tentage. — At  the  time  of  our  inspection  of  Camp  Alger,  Va.,  begin- 
ning August  20, 1898,  the  several  regiments  constituting  the  First  Divi- 
sion of  the  Second  Ami}'  Corps,  together  with  the  three  other  regiments 
belonging  to  a  separate  brigade,  were  all  supplied  with  all  necessary 
tents,  but  the  latter  were  unprovided  with  any  flooring.  This  condi- 
tion as  to  sufficient  tentage  did  not  characterize  the  earlier  days  of 


81 

Camp  Alger,  since,  according  to  the  best  available  testimony,  some  of 
the  regiments  arrived  with  too  little  tentage  for  their  full  strength, 
and  hence  the  men  were,  for  a  time,  too  much  crowded  together  in  the 
tents. 

Rainfall  and  temperature. — Before  taking  up  the  medical  history 
of  individual  regiments,  especially  the  occurrence  of  typhoid  fever  in 
these,  we  may  state  that  very  dry  weather  prevailed  during  the  latter 
part  of  May  and  the  month  of  June,  and  that  it  was  not  until  about  the 
20th  of  July  that  the  first  heavy  rainfall  occurred  at  Camp  Alger. 
This  amounted  to  1.1  inches.  On  the  28th  day  of  June  there  was  a 
fall  of  rain  amounting  to  0. 7  of  an  inch.  During  the  latter  part  of 
July  and  until  the  middle  of  August,  there  were  repeated  heavj^  rain- 
falls ;  but  the  weather  was  dry  during  the  last  half  of  August  and  the 
first  half  of  the  month  of  September,  at  which  time  the  camp  was 
abandoned. 

As  regards  the  temperature,  the  weather  was  extremely  hot,  and 
this  condition  prevailed  practically  during  the  whole  encampment. 
(See  Meteorological  Chart,  Camp  Alger. ) 

First  Division. 

Com7?iands.— Sixty- fifth  New  York  Infantry,  Seventh  Ohio 
Infantry,  First  New  Jersey  Infantry,  Sixth  Illinois  Infantry, 
Sixth  Massachusetts  Infantry,  Eighth  Ohio  Infantry,  Eighth 
Pennsylvania  Infantry,  Twelfth  Pennsylvania  Infantry,  Thir- 
teenth Pennsylvania  Infantry,  Third  Virginia  Infantry,  First 
Connecticut  Infantry,  Troops  A  and  C,  New  York  Cavalry. 

GENERAL  DISCUSSION. 

A  careful  examination  of  the  regimental  histories,  which  have  been 
given  above  at  some  length,  serves  to  bring  out  a  number  of  salient 
features. 

In  the  first  place,  it  will  be  seen  that  some  of  the  regiments  in  the 
First  Division,  while  y&i  in  their  State  encampments,  had  one  or  more 
cases  of  typhoid  fever,  and  that  the  majority  of  these  organizations, 
upon  their  arrival  at  Camp  Alger,  imported  at  least  1  case  of  this  dis- 
ease into  the  Virginia  camp. 

We  will  have  occasion  to  point  out  more  than  once  the  probability, 
in  assembling  1,000  men  in  any  part  of  the  United  States,  that  typhoid 
fever  will  appear  among  them  within  the  period  of  incubation  after 
their  rendezvous. 

We  find  that  the  following  regiments  of  the  First  Division,  Second 
Armj^  Corps,  imported  typhoid  fever  into  the  camp  at  Camj)  Alger: 
Sixty-fifth  New  York,  1  case;  Seventh  Ohio,  1;  Sixth  Massachusetts,  1; 
Sixth  Illinois,  1 ;  Eighth  Pennsylvania,  1 ;  Third  Virginia,  2. 

The  following  regiments  imported  no  case:  First  New  Jersey, 
Eighth  Ohio,  Twelfth  Pennsylvania,  Thirteenth  Pennsylvania,  First 
Connecticut. 

7273 6 


82 

We  do  not  think  that  the  importance  of  keeping  before  us  this  fact 
of  the  importation  of  typhoid  fever  by  regimental  organizations  can 
be  too  much  emphasized,  since,  in  a  number  of  cases,  this  earlj^  impor- 
tation has  been  overlooked  by  the  regimental  medical  officer,  and 
since  this  may  serve  as  a  focus  of  infection  for  other  cases  of  this  dis- 
ease. As  regards  this  division  of  the  Second  Army  Corps,  however, 
in  the  majority  of  instances,  the  disease  having  been  recognized  by 
the  regimental  surgeon,  the  soldier  was  promptly  transferred  to  the 
general  hospital  at  Fort  Myer,  Va.,  a  point  remote  from  the  camp. 

Another  point  to  which  we  desire  to  direct  attention  is  the  consid- 
erable time  which  elapsed  between  the  arrival  of  the  several  regiments 
at  Camp  Alger  and  the  occurrence  of  the  first  case  of  typhoid  fever  in 
these  organizations.     This  is  shown  by  the  following  table : 


?iment. 


Date  of 
arrival. 


Date  of 
occur- 
rence of 

first 
case  of 
typhoid 
fever  at 
Camp 
Alger. 


65tli  New  York 

TthOhio.. 

1st  New  Jersey 

6th  Massachusetts - 

ethlUinois 

8th  Ohio 

8th  Pennsylvania- . 
12th  Pennsylvania- . 
13th  Pennsylvania. . 

3d    Virginia 

1st  Connecticut  ... 


May  20 
Mav  21 
.---do... 
May  23 
May  21 
May  19 
May  18 
May  19 
.--.do-.. 
June  5 
July  19 


June  15 
June  14 
July  2 
June  16 
June  20 
July  13 
June  35 
June  36 
June  20 
June  23 
Aug.    5 


The  Third  Virginia  Infantrj^  and  the  First  Connecticut  Infantry 
developed  their  first  case  in  a  shorter  time  than  the  other  regiments. 
This,  so  far  as  regards  the  last-named  regiment,  is  readilj"  to  be  referred 
to  the  fact  that  this  organization  arrived  at  Camp  Alger  at  a  period 
when  the  camp  was  already  thoroughly  infected  mth  typhoid  fever. 

Another  fact  worthy  of  notice  is  the  small  number  of  cases  which 
are  recorded  for  the  period  ending  June  30,  at  which  time  nine  of  the 
regiments  belonging  to  this  division  had  been  in  camp  on  an  average 
of  forty  days.  (The  Third  Virginia  and  First  Connecticut,  attached 
to  this  division  but  not  brigaded,  did  not  arrive  until  June  5  and  July 
19,  respectively.) 

We  find  the  distribution  of  the  cases  of  typhoid  fever  for  this  period 
as  follows :  Sixty-fifth  New  York,  2 ;  Seventh  Ohio,  1 ;  First  New  Jer- 
sey, none;  Sixth  Massachusetts,  9;  Sixth  Illinois,  2;  Eighth  Ohio, 
none ;  Eighth  Pennsylvania,  2 ;  Twelfth  Pennsylvania,  2 ;  Thirteenth 
Pennsylvania,  1 ;  Third  Virginia,  2  (imported,  2  others). 

It  will  thus  be  seen  that  with  the  exception  of  the  Sixth  Massachu- 
setts no  regiment  had  more  than  2  cases  during  this  period.  The  lat- 
ter regiment  arrived  on  May  22,  had  its  first  case  on  June  2,  followed 
by  a  second  and  third  case  on  June  16  and  18.     We  note  also  that  4 


83 

of  the  9  cases  in  this  regiment  were  confined  to  Company  H,  and  that 
6  of  the  companies  of  this  regiment  had  no  case  up  to  the  time  of 
their  departure  from  Camp  Alger,  July  5,  so  that  this  particular  regi- 
ment is  an  exception  to  the  rule.  The  explanation  is  not  hard  to  find, 
since  this  regiment  was  constantly  on  provost  duty  from  the  time  of 
its  arrival  at  Camp  Alger,  and  hence  the  men  were  subjected  to  addi- 
tional danger  of  infection. 

In  order  to  show  that  the  performance  of  provost  duty  gives  better 
opportunity  for  typhoid  fever  infection,  we  jaaj  cite  the  course  of 
typhoid  fever  in  Troops  A  and  C  of  the  New  York  Cavalry  Squadron, 
which  occupied  an  excellent  camp  site  near  corps  headquarters.  This 
organization,  numbering  6  officers  and  199  enlisted  men,  arrived  at 
Camp  Alger  on  May  23,  and  imported  2  cases  of  typhoid  fever,  1  on 
May  30  and  1  on  June  1,  both  of  which  cases  were  promptly  transferred 
to  the  general  hospital  at  Fort  Myer.  This  organization  was  princi- 
pally used  for  provost  duty,  and  notwithstanding  the  fact  that  its 
water  supply  was  derived  from  a  deep  well  or  was  imported,  as  Hj^geia, 
Apollinaris,  and  such  waters,  and  that  the  well  water  was  boiled,  we 
observe  that  4  additional  cases  of  typhoid  fever  appeared  during  the 
month  of  June,  unquestionably 'due  to  duties  which  would  call  them 
away  from  camp  and  thus  expose  them  to  various  sources  of  infection 
in  the  surrounding  country. 

When  we  take  into  consideration  the  nature  of  the  water  supply  at 
this  camp  during  the  latter  part  of  May  and  a  considerable  part  of  the 
month  of  June  and  the  chances  for  water  pollution,  we  think  it  par- 
ticularly surprising  that  so  few  cases  of  typhoid  fever  can  be  traced 
among  this  division  numbering  more  than  12,000  men.  The  same 
remark  will  apply  still  more  forcibly  to  the  Second  Division  of  the 
Second  Army  Corps  during  this  period.  This,  to  our  minds,  points 
unmistakably  to  the  absence  of  sources  of  infection  at  Camp  Alger 
during  this  time,  and  indicates  clearly  that  these  were  sporadic  cases 
contracted  bj'  the  men  during  their  absence  from  the  camp,  in  the  city 
of  Washington  and  vicinity. 

Lieutenant-Colonel  Smart,  deputy  surgeon-general,  IT.  S.  Army, 
under  date  of  July  13,  1898,  reports  as  follows: 

These  camps,  notwithstanding  their  many  unsanitary  factors,  are  unusually  free 
fi"om  disease.  Vaccinia,  measles,  a  few  venereal  cases  from  proximity  to  Wash- 
ington, and  some  diarrheas  from  irregularities  of  diet  or  from  chill  after  perspi- 
ration and  the  difficulty  of  attending  to  personal  comfort  in  the  crowded  tents, 
constitute  the  sick  list.  In  addition  to  these,  1  found  that  since  the  camp  was 
established  in  May  39  cases  of  typhoid  fever  had  been  reported  and  sent  to  hospital 
for  treatment.  Four  occurred  during  the  month  of  May,  23  in  June,  and  12  up  to 
the  date  of  my  inspection,  in  July.  Taking  the  month  of  June  as  the  second  month 
of  the  aggregation  of  troops  and  rating  the  strength  of  Camp  Alger  during  that 
month  as  20,000,  the  fever  rate  for  the  month  would  be  1.15  cases  per  1,000  men. 

As  a  matter  of  fact,  Colonel  Smart,  relying  uj)on  the  testimony  of 
the  regimental  medical  officers,  reported  fewer  cases  of  tj^jhoid  fever 
up  to  July  13,  1898,  than  had  actually  occurred. 


84 

After  the  most  careful  search,  we  have  been  able  to  trace  up  to  the 
30th  of  June,  a  period  of  about  forty  days  since  the  establishment  of 
the  camp,  excluding  imported  cases,  21  cases  of  this  disease  among 
the  regiments  of  the  First  Division  and  11  cases  among  those  con- 
stituting the  Second  Division;  total,  32. 

Basing  the  calculation  upon  the  mean  strength  of  the  First  Division 
for  the  month  of  June,  namely,  11,137,  we  find  1.88  cases  of  typhoid 
fever  per  1,000  men.  Taking  the  mean  strength  of  the  Second  Divi- 
sion for  the  month  of  June,  namely,  11,257,  we  find  only  0,97  per  1,000 
men.  The  ratio  for  both  divisions  for  the  period  ending  June  30  is 
1.42  per  1,000  men. 

If  we  take  the  period  ending  July  15,  we  find  that  71  cases  of 
recognized  typhoid  fever  have  occurred  in  the  First  Division  and  32 
cases  in  the  Second  Division,  or  a  total  of  103  cases,  as  against  39 
cases  reported  by  Colonel  Smart  for  the  period  ending  July  13,  or  a 
ratio  of  4.06  per  1,000  men  in  a  mean  strength,  for  both  divisions,  of 
25,341.  The  ratio  of  the  First  Division  alone  for  this  period,  based 
upon  the  mean  strength  for  July,  viz,  13,135,  is  5.40;  and  that  for  the 
Second  Division  alone,  also  based  on  the  mean  strength  for  July,  viz, 
12,206,  is  2.62  per  1,000  men. 

It  will  thus  be  seen  that  typhoid  fever  had  made  but  slight  progress 
in  both  divisions  of  the  Second  Army  Corps  up  to  the  period  ending 
June  30,  but  that  during  the  succeeding  fifteen  days,  constituting  the 
first  half  of  July,  the  disease  had  slowly  but  steadily  increased  to  the 
extent  of  4.06  per  1,000  men. 

Returning  to  the  First  Division  which,  all  things  taken  into  consid- 
eration, was  placed  in  less  favorable  circumstances  than  the  Second 
Division,  we  observe  that  contamination  of  the  general  water  supply 
at  a  period  when  this  supply  was  most  questionable  and  most  subject 
to  contamination  does  not  appear  to  have  occurred,  since  we  find  that 
up  to  June  30  of  the  110  company  organizations,  including  1  hospital 
corps  company,  constituting  this  division  at  that  time,  92  companies 
had  had  no  case  of  typhoid  fever,  although  the  water  supply  was  the 
same  for  all  companies  in  each  regiment.  In  other  words,  only  18  com- 
pany organizations  in  this  division  had  experienced  cases  of  typhoid 
fever  up  to  the  30th  day  of  elune. 

We  desire  to  call  attention,  however,  to  the  fact  that,  notwithstand- 
ing the  absence  of  contamination  of  the  general  water  supply,  the  occur- 
rence of  32  sporadic  cases  of  typhoid  fever  among  these  18  company 
organizations,  constituting  so  many  foci  of  infection  internal  to  this 
division,  was  pregnant  with  meaning  for  the  further  spread  of  the 
disease.  It  was  just  at  this  time  that  a  better,  purer,  and  more  abun- 
dant water  supply  had  been  obtained  through  the  sinking  of  a  bored 
well  for  each  regiment ;  but  notwithstanding  this  purer  water  supply, 
typhoid  fever  continued  to  increase.  These  wells  were  of  the  artesian 
class  and  varied  in  depth  from  47  feet  to  156  feet,  only  5  out  of  40 
wells  being  less  than  60  feet  in  depth. 


85 

lu  boring  for  water  a  layer  of  veA-y  impervious  clay  of  varying  thick- 
ness was  met  with.  Below  this  was  found  a  layer  of  rock  into  which 
the  hole  was  drilled  until  a  satisfactory  yield  of  water  was  secured. 
Simultaneously  with  the  boring  of  the  well  a  wrought-iron  pipe  was 
driven  downward  by  repeated  falls  of  a  heavy  weight  until,  when  rock 
was  reached,  a  water-tight  joint  was  made  by  driving  the  pipe  until 
its  cutting  edge  practically  refused  to  go  further. 

We  can  well  believe  the  statement  of  Lieutenant-Colonel  Lusk, 
chief  engineer,  to  whom  we  are  indebted  for  the  foregoing  information 
concerning  the  construction  of  these  wells,  when  he  states  that,  in  his 
opinion,  "these  artesian  wells  were  not  subject  to  surface  contamina- 
tion, owing  to  the  method  of  constructing  them  and  the  character  of 
the  strata  through  which  they  passed."     He  further  adds: 

The  water  supply  in  each  case  appeared  to  come  from  the  extreme  bottom  of  the 
well  and  to  have  no  connection  with  the  ordinary  veins  found  at  slight  depths. 

We  may  here  state  that  following  close  upon  our  inspection  of  this 
division  during  the  latter  part  of  August,  1898,  we  subjected  the  sam- 
ples of  water  from  the  wells  of  the  Eighth,  Twelfth,  and  Thirteenth 
Pennsylvania  Infantry,  of  the  Ninth  Ohio  Battalion,  of  the  well  at 
corps  headquarters,  and  of  the  house  well  near  the  latter,  to  careful 
bacteriological  examination,  and  were  unable-  to  isolate  the  colon 
bacillus  from  any  of  these  sources  except  in  the  case  of  the  house 
well,  which  was  practically  an  open  well,  liable  to  contamination  from 
air  dust.  These  wells  were  all  located  in  the  old  camps  of  the  First 
Division,  which  were  occupied  until  the  beginning  of  August. 

We  also  had  careful  bacteriological  examinations  made  of  the  water 
from  all  the  wells  in  the  new  camp  of  this  division  and  were  able  to 
isolate  a  microorganism  resembling  the  colon  bacillus  in  tT^o  instances, 
namely,  from  the  well  of  the  First  New  Jersey  and  First  Connecticut 
Infantry. 

Notwithstanding  the  purity  of  the  water  supply,  therefore,  and  con- 
trary to  the  generally  accepted  opinion  on  the  part  of  the  medical 
profession,  we  find  that  typhoid  fever  having  been  imported  into 
various,  although  few,  company  organizations  of  this  division,  now 
steadily  advanced;  so  that,  as  compared  with  the  first  fifteen  days  of 
July,  when  only  50  cases  of  typhoid  fever  were  recorded  for  this  divi- 
sion, we  find  during  the  second  half  of  this  month  not  less  than  131 
cases  of  this  disease  have  occurred,  and  that  the  number  of  company 
organizations  affected  increased  from  18  to  35  out  of  a  total  of  74  com- 
panies at  that  time  constituting  the  First  Division. 

The  escape  from  the  occurrence  of  typhoid  fever  of  more  than  one- 
half  of  the  companies  of  this  division  (39)  still  points  unmistakably 
to  the  absence  of  contamination  of  the  general  water  supply. 

The  only  exception  to  the  freedom  from  water  contamination  is  in 
the  case  of  Company  G,  Twelfth  Pennsylvania  Infantry.  By  refer- 
ence to  the  individual  history  of  this  regiment  above  given,  it  will  be 
seen  that  there  is  strong  evidence  pointing  to  the  infection  of  the  shal 


86 

low  well  constructed  by  the  men  of  this  company,  owing  to  close  prox- 
imity to  the  battalion  privj^  It  will  further  be  observed  that  the  large 
number  of  cases  occurring  in  this  particular  company  strongly  con- 
trasts with  the  few  that  occurred  in  the  companies  of  other  regiments 
of  this  division. 

At  this  period,  July  31,  when  cases  of  typhoid  fever  had  occurred, 
in  47  per  cent  of  the  company  organizations  of  the  First  Division,  we 
find,  notwithstanding  change  of  camp  sites  made  by  the  several  regi- 
ments during  the  last  few  days  of  July  or  the  first  week  in  August, 
and  in  spite  of  much  attention  given  to  camp  sanitation,  the  disease 
made  steady  and  rapid  progress  during  August  as  compared  with  the 
month  of  July.  Thus,  we  find  in  a  mean  strength  of  9,464  for  August, 
there  occurred  326  cases  of  recognized  typhoid  fever  in  this  division, 
or  34.44  cases  per  1,000  of  strength. 

If  we  turn  to  the  course  of  this  disease  in  the  several  brigades  of 
thih  division,  we  find  that  the  number  of  cases  per  1,000  men  rises  in 
the  First  Brigade,  composed  of  the  Sixty-fifth  New  York,  Seventh 
Ohio,  and  First  New  Jersey,  to  48.17;  in  the  Third  Brigade,  composed 
of  the  Eighth,  Twelfth,  and  Thirteenth  Pennsylvania,  to  32.63;  while 
in  the  two  regiments  not  brigaded,  consisting  of  the  Third  Virginia 
and  the  First  Connecticut,  it  was  17.36  per  1,000  men.  It  will  be 
recalled  that  from  the  well  water  of  the  last-mentioned  regiment  a 
bacillus  was  isolated  which  somewhat  resembled  the  colon  bacillus. 
(No  calculation  is  made  for  the  Second  Brigade,  as  this  had  left  for 
service  in  Porto  Rico  on  the  5th  day  of  July.) 

The  highest  rate  per  1,000  men  was  attained  in  the  case  of  the 
Sixty-fifth  New  York  Infantry,  in  which,  in  a  mean  strength  of 
1,315  men  for  August,  there  were  123  cases  of  recognized  typhoid 
fever,  or  93.53  per  1,000.  This  regiment  therefore  leads  all  of  the 
regiments  in  the  First  Division  as  regards  prevalence  of  the  disease. 

Before  referring  to  the  individual  record  of  this  regiment,  it  will  be 
seen  that  during  the  month  of  July  there  occurred  24  cases  of  typhoid 
fever,  16  of  which  were  confined  to  Company  E.  It  will  further  be 
seen  that  prior  to  its  removal  from  its  old  camp  site  to  a  new  and 
higher  camp  on  August  8  there  had  occurred  26  additional  cases  of 
typhoid  fever,  and  that  within  twelve  days  following  its  change  of 
camp  site  there  were  44  additional  cases  which  could  be  attributed  to 
infection  in  the  old  camp.  Even  after  the  lapse  of  this  period,  how- 
ever, the  disease  continued  unchecked,  since  we  find  53  cases  occur- 
ring during  the  last  eleven  days  of  August.  There  could  be  no  doubt, 
therefore,  that  the  majority  of  the  companies  of  this  regiment  were 
pretty  well  infected  with  typhoid  fever  prior  to  the  change  of  camp 
site  and  that  the  sources  of  infection,  probably  individual  to  the  com- 
panies, continued  in  the  new  camp. 

We  may  here  state  that  at  tho  time  of  our  inspection  of  this  regi- 
ment, on  the  23d  day  of  August,  1898,  we  found  16  men  on  an  average 


87 

in  each  conical  wall  tent  and  no  provision  made  for  flooring  the  tents. 
In  a  number  of  tents  inspected  by  ns  bedding,  clothing,  together 
with  other  articles,  were  in  contact  with  the  ground  and  thoroughly 
covered  with  dust  and  dirt.  If  tent  infection,  which  we  will  discuss 
in  another  part  of  this  report,  is  concerned  in  the  spread  of  typhoid 
fever,  then  all  of  the  necessary  conditions  were  present,  in  this  regi- 
ment for  the  propagation  of  the  disease  in  this  manner. 

We  here  recall  that  at  the  time  of  our  inspection  our  attention  was 
invited  to  the  fact  that  the  location  of  the  well  of  the  Sixty-fifth  New 
York  in  the  camp  occupied  by  it  during  the  latter  half  of  June,  July, 
and  the  first  week  of  August  was  such  as  to  receive  the  surface  drain- 
age from  the  entire  First  Brigade.  Our  own  inspection  verified  this 
undesirable  location  of  the  well.  It  does  not  follow,  however,  that 
the  water  of  this  well  became  contaminated  so  as  to  constitute  a  fac- 
tor in  the  spread  of  typhoid  fever  in  this  regiment,  since  we  find  that 
of  the  12  companies,  all  of  which  were  making  free  use  of  the  water, 
Companies  C  and  K  had  no  cases  of  typhoid  fever  during  July  or  the 
first  week  in  August,  while  Companies  D,  Gr,  and  I  had  during  July 
and  the  entire  month  of  August,  respectively,  only  4,  7,  and  4  cases. 
Indeed,  typhoid  fever  in  this  regiment  was  largely  confined  during 
August  to 'Companies  A  (12),  B  (11),  C  (16),  E  (9),  F  (25),  and  L  (15). 
We  have  not  therefore  hesitated  to  exclude  this  well  as  the  source  of 
regimental  infection. 

The  inspection  of  the  camp  of  the  Sixty-fifth  New  York  made  by 
the  board  was  followed  by  a  like  inspection  of  the  several  camp  sites 
of  the  regiments  constituting  the  division.  As  a  result  of  this  inspec- 
tion, we  were  gratified  to  find  that  much  care  was  being  given  to  camp 
sanitation,  such  as  the  general  police  of  the  camp  site  and  the  dispo- 
sition of  the  garbage  and  excreta,  although  the  latter,  in  the  majority 
of  regiments,  was  by  no  means  satisfactorily  carried  out.  In  all  sinks 
we  were  able  to  observe  fecal  matter  exposed  to  the  access  of  large 
numbers  of  flies.  An  exception  to  this  statement  was  found  in  the 
case  of  the  Twelfth  Pennsylvania  Infantry,  which  regiment  was 
located  in  a  camp  to  itself  near  Dunn  Loring  Station.  Here  we  found 
that,  by  the  direction  of  the  colonel  commanding,  each  privy  vault 
was  guarded  by  a  regularly  posted  sentinel,  whose  duty  it  w^as  to 
compel  each  soldier  to  cover  his  stool  with  earth  as  soon  as  deposited. 
Not  only  was  this  effectually  carried  out,  but  upon  leaving  the  sink 
the  soldier  was  compelled  to  thoroughly  wash  his  hands  with  soap  and 
water  provided  for  that  purpose. 

We  here  note  that  in  spite  of  change  of  camp  site  and  the  enforce- 
ment of  better  sanitary  police,  typhoid  fever  did  not  markedly 
decrease  in  this  regiment  until  the  beginning  of  the  fourth  week  in 
August,  the  camp  site  having  been  changed  on  August  2. 

During  the  last  two  days  of  August  and  the  early  part  of  Septem- 
ber the  First  Division  of  the  Second  Army  Corps  abandoned  Camp 


88 

Alger,  Ya. ,  the  eight  regiments  constituting  the  division  at  that  time 
taking  their  departure  as  follows:  Twelfth  Pennsylvania,  August 
29;  Eighth  Pennsylvania,  August  30;  Thirteenth  Pennsylvania, 
August  31;  Seventh  Ohio,  September  1;  First  New  Jersey,  Septem- 
ber 2;  Sixty-fifth  New  York,  September  4;  First  Connecticut,  Sep- 
tember 7;  Third  Virginia,  September  8. 

All  these  regiments,  except  the  Eighth,  Twelfth,  and  Thirteenth 
Pennsylvania  Infantry,  left  for  their  State  encampments  and  for 
muster  out  of  the  service  of  the  United  States.  The  Twelfth  Penn- 
sylvania remained  at  Camp  Meade,  Pa.,  only  until  September  19, 
when  it  also  left  for  muster  out  of  service.  The  Eighth  and  Thir- 
teenth Pennsylvania  Infantry  remained  at  Camp  Meade  as  a  part  of 
the  garrison  stationed  at  that  point,  and  later  were  transferred  to 
Camp  Mackenzie,  Augusta,  Ga. 

The  subsequent  course  of  typhoid  fever  in  these  several  regiments 
following  their  departure  from  Camp  Alger  has  already  been  set  forth 
in  the  individual  histories  of  these  regiments  and  need  not  here  be 
further  referred  to,  except  to  state  that  whenever  the  transfer  of  the 
regiment  was  followed  by  enforced  sanitary  measures  tj^phoid  fever 
slowly  but  steadily  decreased;  or  where  the  regiment  already  infected 
with  typhoid  fever  remained  at  its  State  encampment  for  a  period  of 
ten  or  more  days,  as  in  the  case  of  the  First  Connecticut  Infantry, 
the  number  of  cases  of  typhoid  fever  rapidly  increased,  owing,  as  we 
think,  to  new  sources  of  infection  having  been  established  during  this 
time. 

We  have  made  no  reference  thus  far  to  the  course  of  typhoid  fever 
in  the  Second  Brigade  of  the  First  Division,  since  this  brigade,  con- 
sisting of  the  Sixth  Massachusetts,  Sixth  Illinois,  and  Eighth  Ohio 
Infantry,  left  Camp  Alger  on  July  5,  1898,  for  service  in  Porto  Rico 
and  Cuba. 

The  Eighth  Ohio  Infantry  arrived  at  Santiago,  Cuba,  on  July  13. 
By  consulting  the  individual  history  of  this  regiment  it  will  be  seen 
that  one  case  of  typhoid  fever  was  admitted  on  July  12,  and  hence 
points  to  infection  prior  to  the  departure  from  Camp  Alger.  Owing 
to  lack  of  data  no  definite  knowledge  can  be  obtained  concerning  the 
further  occurrence  of  typhoid  fever  in  this  regiment,  except  that 
given  in  its  history  before  mentioned. 

In  the  case  of  the  Sixth  Massachusetts  Infantry  and  the  Sixth  Illi- 
nois Infantry  we  find  that  these  regiments  were  quartered  on  the 
U.  S.  S.  Yale  from  July  8  to  July  25,  and  that  in  the  former  regiment,  it 
having  become  infected  with  typhoid  fever  prior  to  departure  from 
Camp  Alger  owing  to  provost-marshal  duty,  not  less  than  49  recognized 
cases  of  typhoid  fever  occurred  during  the  month,  the  majority  of  the 
cases  having  originated  on  the  voyage  from  Charleston,  S.  C,  to 
Guanica,  P.  R. 

The  Sixth  Illinois  Infantry  had  already  had  2  cases  of  typhoid  fever 


89 

duriug  June  at  Camp  Alger,  but  appears  to  have  largely  escaped  the 
disease  during  the  voj^age  to  the  island  of  Porto  Rico,  since  we  have 
only  found  6  recognized  cases  of  typhoid  fever  for  the  month  of  July. 
The  subsequent  history  of  typhoid  fever  in  this  regiment  is  given  in 
its  individual  history. 

Second  Division. 

Commands. — Twenty-second  Kansas  Infantry,  One  hundred 
and  fifty-ninth  Indiana  Infantry,  Third  New  York  Infantry, 
Seventh  Illinois  Infantry,  Sixth  Pennsylvania  Infantry, 
Fourth  Missouri  Infantry,  Ninth  Ohio  Battalion,  Third  Mis- 
souri Infantry,  First  Rhode  Island  Infantry,  Second  Tennessee 
Infantry,  Hospital  Corps  Company. 

GENERAL   DISCUSSION. 

In  considering  the  origin  and  course  of  typhoid  fever  in  the  Second 
Division  we  desire  to  call  attention  to  the  remarkable  exemption  from 
this  disease  which  the  several  regiments  of  this  division  experienced 
in  their  State  encampments.  No  case  of  tj^phoid  fever  appears  to 
have  actually  occurred  in  any  of  these  regiments  prior  to  their  arrival 
at  Camp  Alger,  Va.,  and  only  two,  namely,  the  Sixth  Pennsylvania, 
encamped  at  Mount  Gretna,  Pa.,  and  the  Second  Tennessee,  encamped 
at  Nashville,  Tenn.,  imported  each  1  case  of  typhoid  fever  into  the 
Virginia  camp. 

In  the  Sixth  Pennsylvania,  which  arrived  at  Camp  Alger,  Va.,  on 
May  19,  we  find  a  case  of  typhoid  fever  admitted  from  Company  K 
on  May  29  and  transferred  to  the  general  hospital  at  Fort  Myer,  Va., 
where  the  diagnosis  was  confirmed. 

In  the  Second  Tennessee,  which  arrived  on  May  29,  we  find  that  a 
case  of  typhoid  fever  was  admitted  from  Company  G  on  the  same 
date. 

We  deem  it  worth  observing  that  6  of  the  regiments  of  the  Second 
Division  were  assembled  at  or  near  western  cities,  and  that  only  3 
were  assembled  near  Eastern  or  Southern  cities. 

Of  the  latter,  typhoid  fever  was  imported  into  Camp  Alger  by  2, 
namely,  the  Sixth  Pennsylvania  and  Second  Tennessee  Infantry. 

We  have  already  referred  to  the  fact  that  the  regimental  camps  of 
this  division  were  less  crowded  for  space  than  those  of  the  First  Divi 
sion,  and  that  up  to  the  period  ending  June  30  only  11  cases  of  typhoid 
fever  had  occurred  in  the  Second  Division. 

Taking  the  mean  strength  of  this  division  for  the  month  of  June, 
namely,  11,257  men,  we  find  a  rate  of  only  0.97  cases  of  typhoid  per  1,000 
men.  This  must  be  considered  as  a  remarkably  low  rate  of  sickness 
from  typhoid  fever  when  we  remember  that  this  regiment  had  already 
been  encamped  at  this  station  an  average  of  thirty-four  days,  and 
this,  too,  during  a  period  when  the  water  supply  was  obtained  from 
various  sources — brooks  and  springs — regarded  by  the  regimental 
medical  officers  as  of  decidedly  questionable  character. 


90 

No  stronger  evidence  could  be  brought  against  the  theory  of  water 
contamination  than  the  fact  that  for  the  period  ending  June  30,  of  the 
113  company  organizations  constituting  the  Second  Division,  only  10 
companies  had  experienced  1  or  more  cases  of  typhoid  fever,  and  these 
companies  were  a  part  of  6  different  regimental  organizations. 
-  By  referring  to  the  occurrence  of  typhoid  fever  in  the  First  Division 
as  compared  with  the  Second  Division,  it  will  be  seen  that  the  typhoid 
rate  per  1,000  men  for  the  same  period  was  1.88,  or  nearly  double 
that  given  for  the  Second  Division,  and  if  we  continue  the  comparison 
during  the  period  ending  July  31  we  find  that  the  occurrence  of 
typhoid  fever  in  the  Second  Division  at  Camp  Alger,  Va.,  still 
remained  less  than  in  the  First  Division,  namely  10.8  per  1,000  men, 
as  compared  with  15.2  for  the  First  Division.  We  observe,  however, 
that  the  comparative  rate  of  increase  is  practically  the  same  for  both 
divisions. 

Foci  of  infection  having  by  the  end  of  June  become  internal  to  this 
division,  we  find,  just  as  we  did  in  the  First  Division,  a  slow  but 
steady  increase  in  the  number  of  cases  of  typhoid  fever,  which  rises 
from  11  cases  during  the  month  of  June  to  135  cases  for  July;  and  we 
note  further  that  all  of  the  regiments  have  now  become  infected.  In 
other  words,  the  sources  of  infection  being  both  internal  and  external 
to  the  camp,  the  chances  for  infection  were  much  multiplied ;  hence 
we  find  by  the  31st  day  of  July  the  number  of  company  organizations 
in  which  typhoid  fever  had  occurred  has  increased  from  10  to  59, 
leaving  still  54  company  organizations,  distributed  among  all  of  the 
regiments  of  this  division,  which  were  as  yet  unaffected  by  the  dis- 
ease. These  noninfected  companies,  it  must  not  be  forgotten,  were 
obtaining  their  water  supply  from  the  general  regimental  supply. 

We  have  already  shown  that  during  the  month  of  August,  while  the 
First  Division  still  remained  at  Camp  Alger,  although  occupying  new 
camp  sites,  typhoid  fever  had  continued  to  increase  rapidly,  reaching 
a  rate  of  34.44  per  1,000  men.  During  the  same  month  the  regiments 
of  the  Second  Division,  which  had  occupied,  with  a  single  exception, 
their  original  camp  sites  from  May  19  to  July  31,  were  placed  under 
different  conditions,  inasmuch  as  they  took  their  departure  from 
Camp  Alger  on  August  3  (Ninth  Ohio  excepted)  and  began  a  march 
to  Thoroughfare  Gap,  via  Bull  Run  and  Bristow  Station,  Va.  This 
march,  which  was  begun  during  extremely  hot  weather,  was  termi- 
nated six  days  later,  when  the  regiments  went  into  camp  at  Thorough- 
fare Gap,  where  they  remained  for  a  period  of  about  two  weeks.  At 
the  end  of  this  time  the  division  was  transported  by  rail  to  Camp 
Meade,  Pa. 

As  this  division  was  ordered  from  Camp  Alger  by  reason  of  the 
prevalence  of  typhoid  fever  in  its  several  regiments,  it  remains  to  be 
seen  what  good  was  attained  in  this  respect  from  the  march  through 
Virginia  to  the  encampment  at  Thoroughfare  Gap.     The  following 


91 

table  will  show  the  number  of  cases  which  occurred  in  each  regiment 
of  this  division  during  July  and  August : 


Regiment. 

July. 

August. 

Regiment. 

July. 

August. 

4 
20 
16 
11 

6 
37 

23 
105 
45 
39 
30 
51 

9tli  Ohio  Battalion 

3 
17 
13 
16 

6 

3d   New  York 

4th  Missouri 

30 

3d    Tennessee 

25 

3d   Missouri 

Total 

46 

131 

389 

During  the  same  time,  in  addition  to  the  389  cases  of  recognized 
typhoid  fever,' there  were  146  cases  of  probable  typhoid  fever  recorded 
as  occurring  among  the  regiments  of  this  division.  Deducting  6  cases 
of  recognized  typhoid  fever  in  the  Ninth  Ohio  Battalion,  which  organi- 
zation did  not  accompany  the  Second  Division  on  its  march  through 
Virginia,  we  find  a  balance  of  383  cases  of  typhoid  fever  in  a  mean 
strength  of  12,164  men,  equivalent  to  31.48  cases  per  1,000  men. 

If  we  compare  the  number  of  cases  of  typhoid  fever  occurring  in 
the  regiments  of  this  division  during  the  first  fifteen  days  in  August, 
and  which  may  be  considered  as  infections  prior  to  departure  from 
Camp  Alger,  and  those  recorded  for  the  last  half  of  August,  we  obtain 
the  following  results : 


Regiment. 

Aug.  1-15 

Aug:  16-31 

Regiment. 

Aug.  1-15 

Aug.  16-31 

34 

48 

9 

15 

8 

15 

31 
57 
11 
24 
20 

3d    Missouri 

21 
20 
13 

26 

159th  Indiana 

1st  Rhode  Island 

31 

3d   New  York 

2d   Tennessee  

13 

6th  Pennsylvania 

7th  Illinois 

Total 

165 

217 

4th  Missouri   . 

Since  the  cases,  217  in  number,  occurring  during  the  latter  half  of 
August  may  be  considered  as  infections  acquired  en  route  to  Camp 
Meade,  Pa. ,  it  will  be  plainly  seen  that  this  division  not  only  failed 
to  shake  off  typhoid  fever,  but  even  experienced  an  increase  of  this 
disease.  We  can  now  readily  see  that  this  was  due  to  the  fact  that 
the  division,  after  marching  for  six  days,  went  into  a  more  or  less  per- 
ma-nent  camp  at  Thoroughfare  Gap,  Va. ,  and  as  each  regiment  was 
already  badly  infected,  there  was  no  reason  why  the  disease  should 
not  continue  to  be  propagated  in  increased  numbers.  Indeed,  the 
very  object  for  which  this  march  was  begun  was  effectually  defeated 
by  the  stay  of  the  division  at  Thoroughfare  Gap  for  a  period  of  from 
ten  to  fourteen  days.  We  do  not  doubt  that  if,  instead  of  camping 
at  this  place,  it  had  been  j)ossible  to  continue  the  march  until  the 
middle  of  August,  typhoid  fever  would  have  been,  to  a  large  extent, 
eradicated  from  the  several  regiments.  From  a  sanitary  point  of 
view,  the  transference  of  this  division  b}^  rail  from  Thoroughfare  Gap, 
Va.,  to  Camp  Meade,  Pa.,  was  a  mistake,  since  each  of  the  regiments 
carried  their  infection  with  them,  and  hence  we  are  not  surprised  to 


92 

find  that  many  cases  of  typhoid  fever  still  continued  to  occur  after 
aiTival  at  the  latter  camp. 

The  subsequent  history  of  the  course  of  typhoid  fever  in  this  divi- 
sion will  be  found  in  the  individual  histories  of  these  regiments,  as 
well  as  under  the  head  of  typhoid  fever  at  Camp  Meade,  Pa. 

It  remains  to  discuss  briefly  the  occurrence  of  typhoid  fever  among 
the  men  of  the  Hospital  Corps  companies  at  Camp  Alger,  Va.,  since 
the  members  of  this  corps  came  into  more  intimate  contact  with  the 
subjects  of  tj'phoid  fever  than  the  men  of  the  regimental  organizations. 

We  have  already  seen  that  during  the  month  of  June  there  were 
only  1.42  cases  of  typhoid  fever  per  1,000  men  in  both  divisions  of  the 
Second  Corps.  During  the  same  period  no  case  of  typhoid  fever 
was  recorded  among  the  men  of  the  Hospital  Corps.  We  begin  to 
appreciate  during  July,  however,  the  danger  involved  in  the  personal 
handling  and  nursing  of  tj-phoid  fever  cases,  especially  by  nurses 
who  were  ignorant  of  the  danger  of  infection,  for  while  the  ratio  of 
cases  per  1,000  men  for  the  two  divisions  reaches  only  4.06,  there  were 
15.3  cases  per  1,000  men  among  the  members  of  the  Hospital  Corps. 
These  ratios  rise  to  25.6  per  1,000  men  for  August,  60.54  for  Septem- 
ber, 53.84  for  October,  and  even  during  November,  when  but  few  cases 
of  typhoid  fever  were  occurring  in  the  Second  Army  Corps,  not  less 
than  7  per  1,000  of  the  men  of  the  Hospital  Corps  were  still  sick  with 
typhoid  fever.  During  this  period  there  were  89  cases  of  recognized 
typhoid  fever  and  18  probable  cases  in  a  mean  strength  of  575  men. 
We  have  been  able  to  record  8  deaths  among  the  recognized  cases,  a 
mortality  of  8.88  per  cent. 

Since  the  hospital  corps  was  divided  into  three  companies  of  about 
200  men  each  and  placed  under  the  best  sanitary  surroundings  noth- 
ing could  point  more  strongly  to  the  danger  of  personal  contact  with 
those  sick  with  typhoid  fever  than  the  foregoing  ratios  of  mor- 
bidity. Failure  to  carry  out  careful  disinfection  of  excreta  and 
neglect  of  hand  disinfection  after  contact  with  cases  of  the  disease 
were  unquestionably  the  important  factors  in  the  propagation  of  the 
infection. 

In  striking  contrast  to  the  high  percentage  of  cases  of  typhoid  fever 
in  the  hospital  corps  may  be  mentioned  the  course  of  the  disease 
amongst  the  200  men  constituting  the  signal  corps  company,  with  a 
record  of  only  6  cases  of  typhoid  fever  for  the  period  May  30  to 
December  31,  1898. 

Separate  Brigade,  Third  Division. 

Commands. — Ninth  Massachusetts  Infantry,    Thirty-third 
Michigan  Infantry.  Thirty-fourth  Michigan  Infantry. 

GENERAL   DISCUSSION. 

It  will  be  seen  that  only  one  of  the  three  regiments  constituting 
this  brigade,  namelj^,  the  Thirty-fourth  Michigan  Infantry,  imported 


93 

a  case  of  typhoid  fever  into  the  Virginia  camp.  No  case  of  this  dis- 
ease had  occurred  at  the  State  encampment.  As  the  regiments  con- 
stituting this  brigade  left  Camp  Alger,  Va.,  on  June  23  and  24, 
sufficient  time  had  not  elapsed  between  their  arrival  and  departure  to 
allow  the  development  of  typhoid  fever  in  their  camps. 

It  has  been  impossible  to  obtain  anj'-  data  of  value  concerning  the 
origin  and  course  of  typhoid  fever  amongst  these  regiments  after  their 
arrival  in  the  island  of  Cuba. 

A  certain  number  of  recruits  for  each  of  these  regiments  arrived  at 
Camp  Alger  after  their  departure  for  Cuba.  Typhoid  fever  appears 
to  have  developed  amongst  the  recruits  left  behind  from  each  regi- 
ment. As  with  the  regiments  of  the  First  and  Second  Divisions,  the 
disease  began  amongst  these  recruits  during  the  latter  pai't  of  July  and 
decidedly  increased  during  August  while  accompanying  the  Second 
Division  on  its  march  through  Virginia. 

Table  showing  for  the  regiments  of  the  Second  Army  Corps  assembled  at  Camp 
Alger,  Va.,  the  mortality  and  morbidity  from  typhoid  fever. 


Regiments. 


Mean 
strength. 


Cases  of  typhoid 
fever. 


Certain. 


Certain 

and 
probable. 


Deaths 
from 

typhoid 
fever. 


Deaths 
from  all 


FIRST  DIVISION. 


65th  New  York.-.. 

7th  Ohio ---- 

1st  New  Jersey  .. 

8th  Pennsylvania - 
13th  Pennsylvania. 
13th  Pennsylvania - 

3d    Virginia 

1st  Connecticut . . 


Total. 


SECOND  DIVISION. 


23d   Kansas 

159th  Indiana , 

3d    New  York 

7th  Illinois. 

6th  Pennsylvania  . 

ith  Missouri 

9th  Ohio  Battalion 

3d    Missouri 

ist  Rhode  lijland  - . 
3d   Tennessee 


Total. 


Total  Second  Army  Corps... 

6th  Illinois  1.-.- 

6th  Massachusetts  ' 

8th  Ohio  1    

New  York  Cavalry,  A  and  C ' 

9th  Massachusetts  ^ 

33d   Michigani _ 

34th  Michigan! 


Total  1 


1,231 
1,169 
1,275 
1,044 

837 

834 

1,141 

1,085 


8.596 


1,199 
1,190 
1,211 
1,319 
1,236 
1,196 
384 
1,165 
1,209 
1,202 


11,211 


19,807 


312 

123 
35 
91 

107 
97 
43 

135 


319 
135 

58 
101 
123 
105 

70 
143 


843 


943 


104 


53 
80 

155 
73 
35 

127 
39 
97 

217 


83 

89 
185 
119 

36 
156 

54 
100 
269 
193 


1,383 


108 


1,807 


3,336 
75 

196 
33 
13 

109 
41 
44 


213 
8 
18 
9 
1 

34 
14 
26 


3,726 


322 


18 
5 
10 
9 
24 
19 
14 


119 


15 

11 

35 

2 

9 

24 

5 

18 

11 

15 


140 


359 
12 
12 
64 
2 
85 
33 
48 


515 


1  Sent  to  Cuba  and  Porto  Rico  after  a  short  stay  at  Camp  Alger. 


94 


Table  showing  for  the  regiments  of  the  Second  Army  Corps  assembled  at  Camp 
Alger,  Va.,  the  mortality  and  morbidity  from  typhoid  fever — Continued. 


Eegiments. 


Deaths  from  ty- 
phoid fever  in 
100  cases  of — 


Certain 
typhoid. 


Certain 
and 

proba- 
ble. 


Per- 
centage 
of  deaths 

from 
typhoid 
to  deaths 
from 
all  dis- 
eases. 


Morbidity  of 
typhoid  fever 
in  1,000  mean 
strength. 


For 
certain 
cases  of 
typhoid. 


For  cer- 
tain and 
probable 
cases  of 
typhoid. 


Deaths 

from 

typhoid 

fever  in 

1,000  of 

mean 

strength 


FIRST  DIVISION. 

65th  New  York 

7th  Ohio.. 

1st  Nevsr  Jersey. 

8th  Pennsylvania 

12th  Pennsylvania 

13th  Pennsylvania 

3d    Virginia 

1st  Connecticut 

Total 

SECOND  DIVISION. 

22d    Kansas 

159th  Indiana 

3d   NewYork 

7th  Illinois 

6th  Pennsylvania 

4th  Missonri  

9th  Ohio  Battalion... 

3d    Missouri — 

1st  Rhode  Island 

2d   Tennessee 

Total 

Total  Second  Army  Corps 


6.60 
3.25 
22.85 
8.79 
21.49 
15.46 
30.23 
14.07 


13.33 


21.15 
10.00 
20.00 
2.77 
17.14 
14.17 
12.82 
9.27 
4.60 


11.20 


11.78 


6.39 
3.20 
13.79 
7.92 
18.69 
14.28 
18.57 
13.38 


77.77 
80.00 
80.00 
88.88 
95.83 
78.94 
92.85 
95.00 


173.62 
105. 21 
27.44 
87.16 
115.91 
117. 83 
37.68 
124.41 


179. 36 
106. 93 
45.  49 
96.74 
146.95 
127.42 
61.34 
130. 87 


11.02 


87.39 


98.06 


109.70 


13.25 
8.98 

16.75 
1.68 

16.66 

11.53 
9.25 
9.00 
3.71 
4.16 


73.33 

72.72 
88.57 

100.00 
66.66 
75.00 

100.00 
69.23 
90.91 
53.33 


43.37 
67.22 

127.99 
59.06 
28.31 

106.18 

101. 56 
83.26 

179. 48 
74.85 


69.22 

74.78 
152. 76 

97.62 

2!).  12 
130.  43 
140.  62 

85.  83 
222. 49 
159. 65 


8.41 


77.14 


85.98 


114.44 


.52 


81.87 


91.23 


112.38 


11.46 

3.42 

6.27 

7.66 

27.47 

18.20 

11.39 

17.51 


12.09 


9.17 

6.72 

25.59 

1.66 

4.83 
15.05 
13.02 
7.72 
8.27 
6.65 


9.63 


10.70 


MALARIAL  DISEASES  IN  THE  SECOND  ARMY  CORPS, 

ALGER,  VA. 


CAMP 


A  comparison  of  the  individual  histories  of  the  several  regiments 
constituting  the  Second  Army  Corps  will  show  that  in  the  large  major- 
ity of  these  regiments  the  diagnosis  of  malarial  disease,  either  as 
intermittent,  remittent,  or  simply  as  malaria,  has  been  given  to  most 
of  the  cases  of  fever  admitted  to  sick  report.  Indeed,  next  to  intes- 
tinal disorders,  malarial  cases  have  contributed  the  largest  number 
to  the  sick  list,  the  relative  figures  being  243.5  cases  per  1,000  for 
intestinal  disorders  and  185.6  cases  per  1,000  for  malarial  diseases. 

As  the  region  round  about  Camp  Alger,  Va. ,  including  the  city  of 
Washington  and  the  district  of  countrj^  lying  along  the  Potomac 
River,  has  been  during  certain  years  well  known  for  the  prevalence 
of  malarial  diseases,  especially  during  the  months  of  July,  August, 
and  September,  it  becomes  necessary  to  look  closely  into  the  matter 
of  the  occurrence  of  malarial  affections  amongst  the  troops  encamped 
at  Camp  Alger,  Va.,  during  the  summer  of  1898. 

If  the  monthly  regimental  reports  are  examined  attentively  and  the 
duration  of  the  supposed  malarial  diseases  accurately  determined,  it 
will  be  found  that  many  of  these  supposed  malarial  affections  lasted 


95 


less  than  twenty-four  hours  and  that  not  less  than  33  per  cent  were 
returned  to  duty  at  the  expiration  of  two  days. 

Another  important  fact  bearing  ujDon  the  nature  of  these  cases  is 
that  in  June,  when  the  occurrence  of  malarial  diseases  is  extremely 
rare  in  the  vicinity  of  Washington,  this  disease  had  already  made 
considerable  progress  in  the  majority  of  regiments  stationed  at  Camp 
Alger,  Va.,  if  the  diagnosis  of  the  regimental  medical  officers  is  to  be 
accepted  as  correct. 

Since,  however,  blood  examinations  were  not  made  in  order  to  sub- 
stantiate the  diagnosis  of  malarial  diseases,  we  do  not  hesitate  to  state 
that,  in  our  opinion,  these  mild  fevers  were  not,  as  a  rule,  of  malarial 
character.  We  believe  that  many  of  them,  perhaps  the  majority, 
were  due  to  intestinal  disturbances  brought  on  through  indiscretion 
in  diet  and  by  the  new  conditions  to  which  the  young  soldier  was 
subjected. 

Concerning  the  cases  of  supposed  malarial  diseases  of  longer  dura- 
tion we  have  already  repeatedly  pointed  out,  in  the  histories  of  indi- 
vidual regiments,  the  large  number  of  cases  which,  upon  transfer  to 
division  or  general  hospitals,  have  been  changed  in  diagnosis  to  typhoid 
fever,  and  we  have  indicated  our  belief  that  many  cases  which  did  not 
last  more  than  ten  days,  or  which  were  furloughed  prior  to  the  time 
when  a  diagnosis  could  be  made,  were  probable  cases  of  that  disease. 

We  will  have  occasion  to  point  out  hereafter  that  the  men  who  were 
subject  to  these  malarial  attacks  had  acquired  a  considerable  immu- 
nity to  subsequent  attacks  of  typhoid  fever  as  compared  with  those 
men  who  did  not  experience  such  supposed  malarial  attacks. 

For  the  purpose  of  more  definitely  clearing  up  the  character  of  these 
cases  this  board  requested  of  the  Surgeon-General  that  a  competent 
observer  should  be  sent  to  Camp  Alger,  Va. ,  for  the  purpose  of  mak- 
ing blood  examinations  of  cases  of  fever  at  that  encampment.  In 
response  to  this  request  Acting  Asst.  Surg.  James  Carroll,  U.  S.  Army, 
visited  Camp  Alger,  Va.,  on  August  24,  26,  and  29.  The  subjoined 
table  gives  the  results  of  the  microscopic  examination  of  the  blood, 
together  with  the  application  of  Widal's  test : 

To  determine  the  general  types  of  fever  at  Camp  Alger,  Va. 


Obsei-vation. 

Commaud. 

History- 

Examina- 
tion for 
malarial 
parasites. 

Widal. 

1.  Wm.  A.  G... 
3.  H.C.R 

Co.  E,  12tli  Penn 
sylvania. 

do.. 

Chilly   sensations   followed   by 
fever.    Believed    to  be  convales- 
cing from  mild  attack  of  malarial 
fever.     Admitted    to  sick  report 
day  after  blood  examination. 
A  number  of  frank  chills,  followed 
by   fever    and    sweating.      Be- 
lieved to  be  convalescing  from 
mild  attack  of  malarial  fever. 
Admitted  to  sick  report  day  af- 
ter blood  examination. 
Chilly    sensations,    followed    by 
slight  malaise.    Not  on  sick  re- 
port. 

Negative. 
do.... 

do.... 

Positive. 
Do. 

3.  H.W.  S 

do ... 

Negative. 

96 

To  determine  the  general  types  of  fever  at  Camp  Alger,  Va.  -Continued. 


Observation. 


Command. 


History. 


Examina- 
tion for 
malarial 

parasites. 


Widal. 


4.  J.H- 


5.  J.  C.  R  . 


6.  F.L. 


7.  Wm.D  .. 

8.  J.  A- 

9.  E.  W.— 

10.  J.  S 

11.  P.J.H... 

12.  S.  J 

13.  J.  F.  C-.. 

14.  W.  C.  W. 

15.  F.  H.S... 


16.  W.  W... 

17.  Wm.  W. 


18.  W.  F.F. 


19.  J.K. 


20.  C.  K  . 


21.  S.  E.  H 


22.  J.E... 


Co.  E,  1st  New 
Jersey. 


Co.  E,7tliOhio._ 


Co.    E,   3d   Mis- 
souri. 


Co.  C,13tli  Penn- 
sylvania. 


Hospital  corps. 


Co.  I,  3d  New 
York. 

Co.  B,  13th  Penn- 
sylvania. 

Co.  B,  1st  New 
Jersey. 

Co.  G,  3d  Vir- 
ginia. 

Co.  B,  65th  New 
York. 

Co.  E,  3d  Vir- 
ginia. 

Co.  B,  7th  Ohio.. 


do 

Band,  65th  New 
York. 


Hospital  corps- 


Co.  A,  1st  New 
Jersey. 


Co.  C,  13th  Penn- 
sylvania. 


Co.  A,  7th  Ohio 


(3o.  G,  7th  Ohio. 


Chilly  sensations  last  night.  Has 
had  similar  sensations  regularly 
every  night  for  5  days,  followed 
always  by  fever.  Is"  taking  qui- 
nine, gr.  3  q.  4  hours.  Diagnosis: 
Malarial  fever. 

Sick  about  1  week.  No  distinct 
chilis,  but  cold  and  warm  sensa- 
tions. Cold  in  the  morning  and 
warm  during  rest  of  the  day  and 
at  night.  Taking  quinine.  Diag- 
nosis: Malarial  fever. 

Sick  4  days  in  hospital.  Has  had 
diarrhea  continuously.  Tem- 
perature remittent  for  the  last  2 
days,  and  has  now  dropped  to 
subnormal.  No  previous  record 
of  temperature.  Taking  quinine. 
Did-gnosis:  Malarial  fever. 

Several  evenings  frank  chills,  fol- 
lowed by  fever  and  sweating. 
Temperature  normal  this  a.  m.; 
is  now  (11  a.  m.)  103.  Diagnosis: 
Malarial  fever. 

Is  semidelirious,  with  subsultus, 
etc.  Roseola.  Diagnosis:  Ty- 
phoid fever. 

In  third  week.  Roseola.  Diagno- 
sis: Typhoid  fever. 

do 


Negative. 


..do-. 


-do.... 


-do. 


Early  stage.  In  hospital  3  days. 
Roseola.  Diagnosis:  Typhoid  fe- 
ver. 

Convalescent.  Diagnosis:  Typhoid 
fever. 

do.... 


Convalescent.  Fourth  week.  Di- 
agnosis: Typhoid  fever. 

Severe  case.  Diagnosis:  Typhoid 
fever. 

do  .- 

Between  third  and  fourth  weeks. 
Temperature  has  reached  nor- 
mal.   Diagnosis:  Typhoid  tever. 

This  man  has  been  nursing  cases 
of  typhoid  fever.  He  is  just 
taken  sick.  Temperature,  lUl. 
Has  coated  tongue,  with  bright 
red  tip  and  margin.    Malaise. 

Sick  5  days.  Has  had  repeated 
chilly  sensations  and  fever.  Tem- 
perature, 99.2  this  morning  and 
Isrisingnow.  Diagnosis:  Remit- 
tent fever. 

Chilly  sensations  and  fever,  with 
sweating,  about  2  weeks  ago. 
Has  also  suffered  from  insomnia 
and  restlessness.  On  sick  report 
1  week.  Regarded  as  a  doubt- 
ful case.  Has  typical  typhoid 
tongue.  One  rose  spot  on  abdo- 
men. Diagnosis  on  admission: 
Ephemeral  fever. 

Cold  sensations,  followed  by  fever 
and  sweating;  chills  repeated 
several  times  a  day  for  several 
days..  Has  been  sick  10  days. 
Has  a  little  temperature  now— 
was  101,3  this  morning.  Diag- 
nosis: Malaria. 

Has  been  sick  2  weeks.  Began 
with  fever.  Never  had  a  chill. 
His  tongue  is  coated  and  the 
edges  are  bright  red.  Diagnosis: 
Malarial  intermittent. 


Negative 


do.. 


.do. 


....do.... 


.do.. 


Negative. 


Partial    re- 
action. 


Positive. 


Partial    re- 
action. 


Positive. 

Do. 
Do. 
Do. 

Do. 

Do. 

Do. 

Do. 

Do. 
Do. 

Negative. 


Positive. 


Do. 


Do. 


Do. 


97 

To  determine  the  general  types  of  fever  at  Camp  Alger,  Va. — Continued. 


Examina- 

Observation. 

Command. 

History. 

■ 

tion  for 
malarial 
parasites. 

WidaL 

33.  M.  McD 

Co.  I.  1st    New 

Sick  about  1  week.    Temperature 

Negative. 

Motility  im- 

Jersey. 

normal;  is  convalescent.    Diag- 
nosis: Remittent  fever. 

p  a  ired, 
and  there 
is  a  slight 
agglutina- 
tion   Con- 
ti  ol  used. 

34.  C.  B 

Co.  A, 7th  Ohio--. 

Says  he  had  a  typical  shake  4  days 
ago,  followed  by  fever  and  sweat- 
ing.    Had  a  light  chill  on  the  fol- 
lowing evening,  but  none  since. 
Has  been  sick  in  all  about  8  days, 
and  is    convalescing.     Does  not 
look    badly,   but    says  he  feels 
very  weak.     Dr.  Palmer  reports 
that  he  found  crescents  and  riilg 
forms  in  this  man's  blood  3  days 

do.--- 

Negative. 

ago.                                                     , 

1 

The  result  of  the  blood  examination  in  the  foregoing  eases,  selected 
at  random,  points  plainly  to  the  typhoid  character  of  the  majority  of 
those  cases  considered  to  be  of  malarial  origin. 

We  have  also  traced  the  cases  of  supposed  remittent  and  intermit- 
tent fever  which  were  transferred  from  the  division  hospitals  at  Camp 
Alger,  Ya.,  to  the  general  hospital  at  Fort  Myer,  Va.  Through  the 
courtesy  of  Acting  Asst.  Surg.  J.  J.  Curry,  pathologist  of  the  latter 
hospital,  to  whom  this  board  is  much  indebted  for  valuable  assistance, 
we  have  been  able  to  follow  92  cases  of  supposed  remittent  fever 
admitted  from  20  regimental  organizations  of  the  Second  Army  Corps. 

In  31  cases  the  disease  was  found  to  be  of  an  entirely  different 
nature,  the  diagnosis  being  changed  to  rheumatism,  f  ebricula,  debility, 
heat  prostration,  pleurisy,  pneumonia,  acute  bronchitis,  acute  diar- 
rhea and  acute  conjunctivitis. 

Of  the  remaining  Gl  cases  of  supposed  remittent  fever,  the  diagno- 
sis was  changed  in  one  case  to  tertian  intermittent  fever  and  in  60,  or 
98. 3  per  cent,  to  typhoid  fever. 

We  are  further  informed  by  Dr.  Curry  that  during  his  service  at 
the  general  hospital  at  Fort  Myer,  Va. ,  where  he  was  daily  conduct- 
ing blood  examinations  from  June  until  September,  he  did  not  find 
the  malarial  parasite  in  any  other  case  of  supposed  malarial  disease 
transferred  from  Camp  Alger. 

If  further  testimony  were  needed  to  show  that  malarial  diseases 
were  extremely  rare  among  the  troops  of  the  Second  Army  Corpis 
stationed  at  Cam^)  Alger,  Va. ,  we  would  point  to  the  First  Connecti- 
cut Infantr}^,  which  left  that  camp  on  September  7,  1898,  and  shortly 
thereafter  transferred  to  hospitals  at  Hartford  and  New  Britain, 
Conn.,  101  cases  of  fever.  Of  these,  we  have  been  informed  by  the 
7273 7 


98 

medical  superintendents  of  the  hospitals  in  the  above-mentioned 
cities,  that  9S  received  the  diagnosis  of  tjq^hoid  fever  and  only  three 
the  diagnosis  of  malaria.  We  have  been  further  informed  that  in  the 
latter  cases  the  diagnosis  of  malaria  was  based  solely  on  the  tempera- 
ture curve,  and  not  upon  blood  examinations. 

As  this  regiment  left  Camp  Alger,  Va.,  at  a  time  when  malarial 
diseases  should  have  been  particularly  rife,  and  as  its  regimental  camp 
site  and  the  conditions  under  which  its  men  were  placed  were  not 
exceptional,  the  irrefutable  evidence  above  given  as  to  the  character 
of  its  fevers  will  show  that  notwithstanding  the  opinions  of  the  regi- 
mental medical  officers,  malarial  fever  did  not  exist,  save  to  an  unim- 
portant extent,  at  Camp  Alger,  Va. 

We  have  already  expressed  our  belief  that  manj"  of  these  short 
fevers  were  due  to  errors  in  diet  and  to  the  changed  conditions  sur- 
rounding the  young  soldier.  We  have  also  entertained  the  opinion 
that  some  of  these  fevers  of  shorter  duration  might  be  due  to  infec- 
tion with  the  typhoid  bacillus,  and  hence  were  to  be  considered  as 
cases  of  mild  or  abortive  typhoid  fever. 

The  coincident  rise  and  fall  of  these  fevers  with  that  of  the  occur- 
rence of  recognized  typhoid  fever  in  certain  companies  and  regiments 
has  led  us  to  look  more  carefully  into  this  subject.  For  this  purpose 
we  have  with  much  labor  followed  all  cases  of  fever,  of  whatever 
character,  occurring  in  19  regiments  between  June  1  and  December 
31,  1898,  in  order  to  ascertain  how  many  of  these  men  afterwards  con- 
tracted typhoid  fever. 

We  have  also  carefully  followed  for  the  same  period  all  soldiers  in 
these  regiments  who  did  not  have  these  supposed  malarial  attacks, 
with  the  object  of  finding  out  whether  these  men  were  more  or  less 
susceptible  to  attacks  of  typhoid  fever. 

In  conducting  this  investigation  we  have,  followed  by  name,  com- 
pany, and  regiment  every  soldier  in  these  19  regiments  of  the  Second 
Army  Corps  who  was  admitted  to  sick  report  with  any  form  of  febrile 
disturbance,  no  matter  what  diagnosis  was  given  to  the  latter,  and 
have  only  excluded  those  in  which  the  febrile  condition  was  after- 
wards plainly  shown  to  be  a  part  of  the  typhoid  attack.  All  other 
cases  have  been  reckoned  under  the  head  of  "Preceding  malarial  dis- 
eases," since  this  was  the  diagnosis  largely  given  to  these  cases.  We 
have  included,  of  course,  supposed  malarial  attacks  occurring  during 
the  month  of  June,  when  typhoid  fever  did  not  prevail.  Had  we 
excluded  these  cases,  which  we  might  have  properly  done,  and  only 
included  those  shorter  fevers  which  prevailed  during  the  epidemic  of 
typhoid  fever,  namely,  during  July,  August,  and  September,  the  per- 
centage of  these  cases  which  were  afterwards  followed  by  typhoid 
fever  would  have  been  still  less. 


99 


The  results  obtained,  from  this  investigation  are  embodied  in  the 
following  table: 

Cases  of  typhoid  fever  among  men  with  or  ivithout  preceding  malarial  disease. 


Mean 
strength. 

Cases  of 
malaria. 

Typhoid  fever 
with  preced- 
ing malaria. 

Men  not 
having 
had  ma- 
laria. 

Typhoid  fever 
without  preced- 
ing malaria. 

Total 

cases 

Regiments. 

Num- 
ber of 
cases. 

In  100 
mala- 
rial 
cases. 

Num- 
ber of 
cases. 

In  100  in- 
dividuals 
without 
malaria. 

of  ty- 
phoid 
fever. 

1,168 
1,193 
1,273 

211 
236 
210 

7 
3 
1 
1 

13 
1 

3.3 

1.3 
.4 
.5 

8.0 
.3 

957 

956 

1.063 

1,029 

1,154 

915 

1,237 

1,178 

891 

848 

659 

1,014 

931 

616 

547 

1,065 

934 

907 

1,025 

91 

119 

100 

50 

127 

51 

35 

34 

80 

89 

104 

39 

85 

97 

211 

157 

73 

193 

154 

9.5 
12.4 
9.4 
3.8 
11.0 
5.5 
2.8 
3.8 
8.9 
10.4 
15.7 
3.8 
9.3 
15.7 
38.5 
14.7 
7.7 
21.3 
15.0 

98 

4th  Missouri 

133 

7th  Ohio      

101 

7thIlllinois     

1,303  !■        174 
1,303  1         149 
1,315  1         300 
1,343  1         106 
1,234  1           56 
1,194  '         303 
1,049  1         201 
823  1          164 
1, 123            109 

51 

139 

53 

35 

6th  Pennsylvania 

159th  Indiana             

1 
1 

3 
3 

1.7 
.3 
.9 

1.8 

35 
81 

8th  Pennsylvania 

13th  Pennsylvania 

91 
107 
39 

3d   Tennessee-   

1,096 
795 
1,085 
1,218 
1,213 
1,201 
1,361 

175 
179 
538 
153 
389 
394 
336 

3 

1.7 

88 
97 

10 
5 
5 
7 
1 

1.8 
3.3 
1.7 
2.3 
.4 

231 

65th  New  York 

162 

6th  Illinois         

77 

6th  Massachusetts 

3d   New  York      

200 
155 

Total 

31,988 

4,083 

63 

1.5 

17,905 

1,888 

10.5 

1,951 

An  examination  of  this  table  will  show  that  in  a  mean  strength  of 
21,988  men  there  were  4,083  who  experienced  attacks  of  fever,  which 
was  generally  designated  as  some  form  of  malarial  disease,  most  fre- 
quently as  remittent  malarial  fever.  Of  this  number  only  63,  or  1.5 
per  cent,  suffered  from  subsequent  attacks  of  typhoid  fever.  On  the 
other  hand,  of  17,905  men  who  did  not  experience  any  attack  of  sup- 
posed malarial  fever,  1,888,  or  10.5  percent,  contracted  typhoid  fever. 
In  other  words,  those  soldiers  who  had  fevers  of  short  duration  and 
which  were  generally  designated  as  malarial  fever  were  seven  times 
less  liable  to  subsequent  attacks  of  typhoid  fever  than  those  who  had 
not  suffered  with  these  milder  fevers. 

To  put  the  subject  in  another  way,  of  1,951  men  who  had  recognized 
typhoid  fever,  63,  or  3.2  per  cent,  had  preceding  attacks  of  supposed 
malarial  fever,  while  1,888,  or  96.7  per  cent,  had  no  such  preceding 
attacks. 

We  thus  see  that  these  fevers  of  milder  form,  occurring  during  the 
time  when  typhoid  fever  was  epidemic  in  the  regiments  at  Camp 
Alger,  Va.,  conferred  a  remarkable  immunity  against  subsequent 
attacks  of  typhoid  fever.  This  was  not  found  to  be  the  case  in  only 
a  few  selected  regiments,  but  in  all  regiments  studied  in  the  Second 
Army  Corps.  Similar  results,  even  more  striking,  have  been  obtained 
from  a  careful  study  of  the  regiments  of  other  army  corps. 

Bearing  upon  this  point,  we  submit  herewith  a  diagram  showing 
the  curve  of  recognized  cases  of  typhoid  fever  in  these  19  regiments 


100 

of  the  Second  Arm}'  Corps  and  in  7  regiments  of  the  Third  Division, 
Seventli  Corps,  for  the  period  May  30  to  November  30,  1898,  together 
with  a  curve  for  supposed  malarial  diseases  during  the  same  period. 
It  will  be  seen  that  there  is  a  remarkable  similarity  between  the  rise 
and  fall  of  these  two  diseases,  and  what  is  particularly  striking  is  the 
marked  fall  in  supposed  malarial  diseases  during  the  month  of  Sep. 
tember,  which  is  contrary  to  what  would  have  occurred  in  the  vicinity 
of  Washington  during  the  latter  month.  Observations  extending  over 
twenty-six  years,  made  by  one  of  the  members  of  this  board,  have 
demonstrated  that  the  month  of  September  gives  the  highest  rate  for 
malarial  fevers  in  and  near  the  city  of  Washington,  D.  C. 

Typhoid  and  malarial  fever  at  Camp  Alger,  Va.,  and  Jacksonville,  Fla. 
EIGHTEEN  ALGER  REGIMENTS. 


Typhoid  fevers. 


Months. 


Mean 
.strength. 


Num- 
ber of 
cases. 


In  1,000 
of  mean 
strength. 


Malarial  fevers. 


Num- 
ber of 
cases. 


In  1,000 
of  mean 
strength. 


May-- 

June 

July -- 

August 

September. 

October 

November . 


16,051 
19, 364 
21,356 
21.392 
20. 785 
19, 896 
15,a30 


7 
31 
321 
874 
593 
262 
55 


0.43 
1.60 
15.17 
40.84 
28.53 
13.16 
3.59 


117 
415 
549 
1,147 
865 
302 
145 


7.16 
21.42 
25. 70 
53.61 
41.61 
15, 17 

9.45 


SEVEN  JACKSONVILLE  REGIMENTS. 


May 

June 

July 

August 

September 

October 

November. 


3,699 

5 

3,974 

17 

4.27 

81 

8,426 

49 

5.81 

244 

8,505 

188 

22.10 

480 

8,175 

577 

70.59 

731 

7,736 

365 

47.18 

466 

6,936 

70 

10.09 

270 

L35 

20.38 
28. 95 
56.43 
89.41 
60.23 
38.92 


It  was  later  a  matter  of  considerable  regret  to  this  board  that  the 
opportunity  had  not  been  utilized  to  submit  samples  of  blood  from 
these  so-called  malarial  fevers  to  the  Widal  test.  Frankly  speaking, 
this  was  not  done  at  the  time  of  our  inspection  of  Camp  Alger,  Va., 
because  we  were  not  prepared  to  regard  these  shorter  fevers  as  mild 
\  infections  due  to  the  typhoid  bacillus.  This  opinion  was  only  arrived 
at  after  the  opportunity  for  making  use  of  this  material  had  passed. 

Fortunately,  one  of  the  members  of  this  board  was  ordered  to  Cuba 
for  the  purpose  of  studying  an  outbreak  of  typhoid  fever  in  the  camp 
of  the  Eighth  U.  S.  Cavalry,  near  the  city  of  Puerto  Principe.  At 
this  camp,  in  addition  to  well-marked  cases  of  typhoid  fever  of 
average  severity,  there  were  seen  in  the  department  hospital  cases  of 
much  milder  type  and  which  for  this  reason  were  designated  by  the 
surgeon  in  attendance  as  remittent  malarial  fever. 

With  the  object  of  ascertaining  the  character  of  these  milder  fevers, 
samples  of  blood  were  taken  from  all  fever  cases  in  the  wards  of  the 
department  hospital  and  afterwards  subjected  to  the  Widal  test. 


DIAGRAM  SHOWING,  FOR  CAMP  ALGER  AND  JACKSONVILLE, 
THE  PROPORTION  OF  CASES  OF  TYPHOID  AND  MALARIAL  FEVERS 
IN  1000  OF  MEAN  STRENGTH 


CAMP  ALGER 

JACKSONVILLE 

MAY 
JUNE 
JULY 
AUG 
SEPT 
OCT 
NOV 

MAV 

JUNE 

JULY 

AUG 

SEPT 

OCT 

NOV 

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MISSOURI 

NUOM                                                                          '*"•> 

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N3A3                                                           <^" 

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NAME 
J.B.K. 

DIAGNOSIS 
MALARIAL   FEVER  -  REMITTENT 

to 

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DIAGNOSIS 

MALARIAL  FEVER 
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00 

N3y\.3              III         "■*-* 

Naow                                         ^> 

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NATIVITY 
ILLINOIS 

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NAME 
C.P.A. 

DIAGNOSIS 
MALARIAL  FEVER-REMITTENT 

N 

N3A3     [                                 T         T               T                       ,^^ 

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NATIVITY 
GERMANY 

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z 

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z 

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1 

5 

u     gooogo>o>o><» 

DIAGNOSIS 

MALARIAL  FEVER 
REMITTENT 

K 

N3A3                                                              v^J 

NMpW                                                                     T> 

(O 

N3A3                                                           <-' 

Naow                                        ^^ 

U) 

N3A3                                                      <^ 

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^ 

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OS 

to 

N3A3                                                           ^' 

NilOIN                                                             ^ 

CM 

NaA3                                                           / 

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NATIVITY 

ILUNOIS 

1 

N3A3                                            *'"--l-> 

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O 

to 

N3A3                                            *'''T 

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CM 

N3A3                               -si'                                        J 

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1- 

o  i\ 

UI  * 

00 
M 

NaA3                            **-->. 

Naow                                         "'^^> 

NSAs                       «:; 

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CM 

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NaOM                             .SX-''"               A                   1 

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CM 

N3Aa    -•"' 

NMOW                                     [                                                      J_ 

NAME 
H.K. 

DAY  OF  MONTH 
APRIL 

> 
< 

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u 

h 

101 


Thirteen  of  these  cases  were  diagnosed  as  typhoid  fever  and  16  as 
malarial  fever  remittent.     The  result  of  the  test  was  as  follows : 

Of  the  cases  diagnosed  as  tj^phoid  fever,  a  positive  reaction  was 
obtained  in  10,  an  incomplete  reaction  in  2,  and  a  negative  reaction 
in  1  case.  Of  the  cases  diagnosed  as  malarial  fever  remittent,  a  posi- 
tive reaction  was  obtained  in  12  and  a  negative  reaction  in  4  cases. 

Through  the  kindness  of  Major  Armstrong,  brigade  surgeon,  U.  S. 
Army,  chief  surgeon  of  the  department,  we  are  able  to  present  here- 
with a  few  charts  of  these  supposed  malarial  fevers  of  short  duration 
in  which  the  Widal  reaction  was  positive. 

Since  typhoid  fever  is  frequently  manifested  by  symptoms  of  intes- 
tinal disturbance  as  well  as  fever,  and  since  these  two  symptoms 
may  be  relatively  more  or  less  prominent  in  different  cases,  we  have 
thought  that  perhaps  many  cases  of  this  disease  in  more  resistant 
individuals  would  occur  as  simple  diarrheas  without  attracting  par- 
ticular attention. 

We  have  therefore  made  a  like  effort  to  ascertain  what  percentage 
of  those  soldiers  having  intestinal  disturbances  subsequently  con- 
tracted typhoid  fever  as  compared  with  those  who  had  not  suffered 
from  intestinal  disturbances.  Here,  too,  we  have  excluded  those 
intestinal  attacks  which  were  a  part  of  the  typhoid  attack.  The 
subjoined  table  will  indicate  the  results  obtained. 
Cases  of  typhoid  fever  among  men  with  or  without  preceding  diarrheal  attacks^. 


1=1 

m 

Cases  of  diar- 
rheal disease. 

Typhoid  fever 
with  preced- 
ing diarrhea. 

Men 

not 
having 
had  di- 
arrhea. 

Typhoid  fever 
without  pre- 
ceding diarrhea. 

Total 

Regiments. 

Num- 
ber of 
cases. 

In  in- 
divid- 
uals. 

Num- 
ber of 
cases. 

In  100  in- 
divid- 
uals 
with  di- 
arrhea. 

Num- 
ber of 
cases. 

In  100  in- 
divid- 
uals 
without 
diarrhea. 

of  ty- 
phoid 
fever. 

1,168 
1,192 
1,272 
1,303 
1,303 
1,215 
1,343 
1,234 
1, 194 
1,049 

833 
1,123 
1,096 

795 
1,085 
1,318 
1,213 
1,301 
1,261 

364 
185 
100 
289 
639 
247 
164 

76 
180 

57 

43 
331 

70 
381 
149 

97 

130 

1,746 

317 

5,354 

331 
176 

96 
247 
468 
228 
151 

69 
170 

57 

41 
198 

70 
221 
137 

94 
108 
772 
260 

16 
3 
4 
11 
33 
3 
3 

4.8 
1.1 
4.1 
4.4 
6.8 
1.3 
1.9 

837 

1,016 

1,176 

956 

835 

987 

1,193 

1,165 

1,024 

992 

783 

925 

1,026 

574 

948 

1,134 

1,105 

429 

1,001 

83 

130 

97 

40 

107 

49 

33 

35 

73 

91 

106 

34 

84 

77 

314 

1.58 

76 

165 

137 

9.7 

11.8 

8.2 

4.1 

13.8 

4.9 

3.6 

3.0 

7.1 

9.1 

13.5 

3.6 

8.1 

13.4 

33.5 

14.0 

6.8 

38.4 

13.6 

98 

4th  Missouri 

133 

7th  Ohio    

101 

7th  Illinois  

51 

1st  Connecticut 

139 

53 

1st  New  Jerisey 

6th  Pennsylvania 

159th  Indiana 

85 
35 

8 

4.7 

81 

8th  Pennsylvania 

12th  Pennsylvania 

3d    Virginia.. 

2d    Tennessee 

13th  Pennsylvania 

1st  Rhode  Island 

65th  New  York 

6th  Illinois     

91 

1 
5 

4 
30 
7 
4 
1 

35 
18 

3.4 
3.5 
5.7 
9.0 
5.1 
4.3 
.9 
4.5 
6.9 

107 
39 
88 
97 
331 
163 
77 

6th  Massachusetts 

3d   New  York 

300 
155 

Total 

21,988 

3,894 

174 

4.4 

18,094 

1,777 

9.8 

1,951 

This  table  will  show  that  of  3,894  individuals  who  suffered  with 
some  form  of  diarrheal  disturbance  only  174,  or  4.4  i^er  cent,  subse- 
quently contracted  typhoid  fever;  whereas  of  18,094  men  who  had  no 
intestinal  disorder  not  less  than  1,777,  or  9.8  per  cent,  fell  victims  to 
typhoid  fever. 

In  other  words,  those  soldiers  who  were  free  from  attacks  of  diar- 


102 


rhea  were  more  than  twice  as  liable  to  contract  t^T^hoid  fever.  Indeed, 
if  we  deduct  those  cases  of  typhoid  fever  in  which  the  attack  of  diar- 
rhea occurred  during  the  month  of  June,  at  a  time  when  tj^phoid  had 
scarcely  begun,  and  which  diarrheas  could  not,  therefore,  have  been 
protective,  we  find  that  the  percentage  of  those  subsequentlj'  contract- 
ing typhoid  fever  falls  still  lower.  In  order  to  determine  this  point 
we  herewith  submit  a  table  relating  to  four  regiments  of  the  Second 
Army  Corps,  taken  at  random,  in  which  cases  of  typhoid  fever  pre- 
ceded by  diarrheas  occurring  during  the  month  of  June  have  been 
excluded : 

Cases  of  typhoid  fever  among  the  men  of  four  regiments  of  the  Second  Army  Corps, 
taken  at  random,  tvith  or  ivithout  preceding  diarrheal  attacks,  June  diarrheas 
excluded. 


■s 

§ 

m 
® 

Cases  of  diar- 
rheal disease. 

Typhoid  fever 
with  preced- 
ing diarrhea. 

Men 

not 

having 

haddi 

arrhea. 

Typhoid  fever 
without  pre- 
ceding diarrhea. 

Total 

Regiments. 

Num- 
ber of 
cases. 

In  in- 
divid- 
uals. 

Num- 
ber of 
cases. 

In  100  in- 
divid- 
uals 
with  di- 
arrhea. 

In  100  in- 
Num-      divid- 
ber  of        uals 
cases,    without 

diarrhea. 

1 

of  ty- 
phoid 
fever. 

1,168 

1,303 

795 

1,261 

364 
289 
281 
317 

331 

247 
221 
260 

2 

6 
4 

0.3 

.2 
2.7 
1.5 

837 

956 

574 

1,001 

82 

40 

77 

137 

9.7 
4.1 
13.4 
13.6 

84 

43 

13th  Pennsylvania 

3d   New  York   -. 

83 
141 

Total                

4,437 

1,251 

1,0.59 

14 

1.3 

3,368 

336             9.9 

350 

An  examination  of  the  foregoing  table  will  show  that  the  men  who 
suffered  from  diarrheal  attacks  during  those  months  when  typhoid 
fever  was  prevailing  at  Camp  Alger,  Va.,  were  seven  times  less  liable 
to  contract  typhoid  fever  than  those  who  had  no  diarrhea. 

Taking  the  total  number  of  recognized  cases  of  typhoid  fever  in  these 
nineteen  regiments,  viz,  1,951,  we  find  that  174,  or  8.9  per  cent,  were 
preceded  by  diarrhea,  while  1,777,  or  91.9  per  cent,  had  no  previous 
diarrheal  disturbance. 

We  therefore  conclude  that  many  of  these  supposed  diarrheas  were 
really  manifestations  of  infection  by  the  typhoid  bacillus,  since  we 
can  not  otherwise  account  for  the  protective  influence  here  so  strik- 
ingly manifested. 

We  believe  that  the  facts  which  we  have  here  gathered  point  irre- 
sistibly to  the  conclusion  that  at  Camp  Alger,  Va. ,  in  addition  to  the 
occurrence  of  a  large  number  of  recognized  cases  of  typhoid  fever  of 
average  duration  and  severity,  there  were  a  still  larger  number  of 
milder  infections  appearing  as  simple  diarrlieas  or  as  fevers  of  short 
duration.  We  shall  have  occasion  to  draw  the  same  conclusion  from 
our  study  of  typhoid  fever  in  the  other  army  corps. 

ORIGIN  AND  SPREAD  OF  TYPHOID  FEVER  AT  CAMP  ALGER,  VA. 

There  was  nothing  in  the  general  topography  of  Camp  Alger,  Va., 
that  should  have  made  it  an  unhealthy  camp  site.     Its  general  eleva- 


103 

tion  above  the  Potomac  River  was  about  300  feet,  while  the  surface 
was  rolling  and  well  drained. 

The  lack  of  a  good  natural  water  supply  should  have  prevented  the 
rapid  concentration  of  a  large  number  of  regiments  at  this  point.  We 
have  already  seen  that  one  source  of  discomfort  in  the  early  history 
of  the  camp  was  the  lack  of  sufficient  water,  and  that  to  this  was 
added,  in  the  case  of  some  of  the  regiments,  overcrowding  of  the  camp 
site.  Notwithstanding  this,  typhoid  fever  furnished  only  1.42  eases 
per  1,000  men  during  the  first  fortj^^  days  of  the  encampment. 

We  have  already  pointed  out  that  typhoid  fever  was  imported  into 
this  camp  by  a  number  of  the  regimental  organizations,  and  that 
sources  for  additional  individual  infections  could  be  found  in  the  city 
of  Washington  and  surrounding  country.  The  origin  of  the  disease  is 
therefore  plain. 

As  to  the  matter  of  the  further  propagation  of  this  disease,  until  it 
had  assumed  epidemic  form  there  did  not  appear  to  be  any  doubt  on 
the  part  of  the  various  medical  officers  on  duty  at  Camp  Alger  at  the 
time  of  our  inspection  but  that  the  water  supply  was  at  fault.  The 
condemnation  of  the  latter  and  of  the  shacks  at  which  food  and 
drinks  of  different  kinds  were  sold  was  unanimous. 

Although  no  positive  evidence  showing  undoubted  water  contami- 
nation was  presented,  we  were,  nevertheless,  impressed  with  the  pos- 
sibility of  this  pollution  of  the  supply,  and  hence  in  our  letter  of 
recommendation  addressed  to  the  adjutant-general  of  the  First  Divi- 
sion on  August  24,  1898,  we  emphasized  the  necessity  for  the  detail  of 
two  men  in  each  company  who  should  look  after  the  sterilization  of 
the  water  by  boiling,  and  its  careful  storage  in  barrels. 

Our  subsequent  careful  study  of  the  occurrence  of  typhoid  fever  by 
company  organizations  has  convinced  us  that  the  spread  of  the  disease 
by  contamination  of  the  water  supplj^  can  not  be  sustained,  except  in 
the  case  of  Company  G,  Twelfth  Pennsylvania  Infantry.  This  local 
company  epidemic  has  been  carefully  commented  on  in  the  history  of 
the  Twelfth  Pennsylvania  Infantry. 

We  must  look,  therefore,  to  other  modes  of  propagation  than  that 
of  the  water  supply. 

Upon  the  completion  of  our  inspection  at  this  camp  we  were 
impressed  with  the  x)ossibility  of  the  spread  of  typhoid  fever  by  tent 
infection,  although  at  the  time  we  had  not  obtained  any  positive  data 
bearing  on  this  particular  mode  of  propagation  of  the  disease.  It  was 
because  of  this  belief  that  we  made  the  following  recommendation : 

We  earnestly  hope  that  the  flooring  of  the  tents,  which  has  already  been  ordered, 
will  be  speedily  put  in  position.  It  is  certainly  nnwise  to  allow  soldiers  to  sleep 
in  the  dirt  and  dust  of  their  tents  (as  they  are  doing  now,  for  instance,  in  the 
Sixty-fifth  New  York  Infantry).  Filth, possibly  some  of  it  infected  with  specific 
germs,  may  be  and  undoubtedly  is  brought  from  the  most  diverse  sources  into 
these  tents  on  the  feet  of  the  men,  tramped  in  the  dust  in  which  they  sleep,  and 
particles  of  it  talcen  into  their  naso-pharynx.  The  board  thinks  it  possible  that  the 
epidemic  in  Company  E,  bixty-tifth  New  York  Infantry,  was  spread  in  that  way. 


104 

Since  th.e  above  recommendation  was  made  we  have,  in  the  course 
of  our  investigation,  obtained  much  valuable  evidence  bearing  on  this 
mode  of  infection.  This  will  be  presented  under  the  study  of  typhoid 
fever  at  Camp  Meade,  Pa.  We  would  therefore  include  tent  infec- 
tion as  one  of  the  agencies  concerned  in  the  spread  of  typhoid  fever 
at  Camp  Alger,  Va. 

We  especially  recommended  the  most  careful  supervision  of  the 
company  sinks,  and  that  each  soldier  be  required  to  cover  his  excre- 
ment with  dry  earth  as  soon  as  deposited.  This  was  intended  to 
avoid,  as  far  as  possible,  the  contamination  of  food  and  drink  by 
means  of  flies,  and  also  for  the  purpose  of  minimizing  the  possibility 
of  contamination  of  the  soldier's  person  at  the  company  sinks.  We 
are  of  the  opinion  that  typhoid  fever  was  spread  in  this  camp  in  both 
of  these  ways. 

We  would  also  include  as  a  factor  in  the  spread  of  this  disease  the 
undoubted  pollution  of  the  soil  with  the  urine  of  those  suffering  with 
typhoid  fever.  Cases  of  this  disease  under  the  diagnosis  of  malarial 
fever  of  one  kind  or  another  were  repeatedly  treated  by  the  regi- 
mental surgeon  throughout  the  entire  sickness.  Patients  still  con- 
valescing were  also  returned  to  their  respective  companies. 

Since  the  investigations  of  Richardson,  Horton  Smith,  and  others 
have  shown  that  the  urine  of  the  sick  and  convalescents  from  this 
disease  frequently  (20  to  25  per  cent)  contains  typhoid  bacilli  in  large 
numbers,  there  must  have  been  abundant  opportunity  for  the  con- 
tamination of  the  soil  with  the  specific  germ. 

Finally,  we  do  not  doubt  that  the  disease  was  convej^ed  from  the  sick 
to  the  well  in  the  division  hospitals,  and  that  the  utterlj^  inadequate 
methods  of  disinfection  of  stools,  of  the  surface  of  the  patient's  body, 
and  of  the  infected  bedding  and  clothing,  contributed  to  this  mode  of 
propagation. 

CHAPTER  VIII. 

TYPHOID  FEVER  IN  THE  SECOND  ARMY  CORPS,  CAMP  MEADE,  PA. 

Covimands. — First  Maryland  Infantry,  Thirty-fifth  Michi- 
gan Infantry,  Tenth  Ohio  Infantry,  Third  Connecticut  Infan- 
try, Two  hundred  and  second  New  York  Infantry,  Fifteenth 
Minnesota  Infantry,  Second  Pennsylvania  Infantry.  Foui'th 
New  York  Infantry,  Two  hundred  and  third  New  York  Infan- 
try, Second  West  Virginia  Infantrj^  Fifth  Massachusetts 
Infantry,  Two  hundred  and  first  New  York  Infantry,  First 
Delaware  Infantry,  Seventh  Ohio  Infantry.  Eighth  Penn- 
sylvania Infantry,  Twelfth  Pennsylvania  Infantry,  Thir- 
teenth Pennsylvania  Infantry,  First  Rhode  Island  Infantry, 
Second  Tennessee  Infantry. 

General  remarks. — This  camp  site  was  chosen  as  favorable  ground 
for  a  second  encampment  of  the  regiments  of  the  Second  Army  Corps, 


105 

v.hieli  had  already  suffered  to  such  an  extent  from  tj^phoid  fever  at 
Camp  Alger,  Va.  It  is  situated  a  few  miles  west  of  Middle  town,  Pa. , 
and  on  the  north  bank  of  the  Susquehanna  River. 

Top()graj)liij. — A  detailed  topographical  map  of  the  camp  site  could 
not  he  obtained.  The  general  elevation  of  the  regimental  camp  sites 
above  the  river  was  about  50  to  80  feet.  This  site  was  well  suited  for 
the  encampment  of  troojjs,  being  elevated,  rolling,  and  exceptionally 
well  drained.  At  the  time  of  our  inspection  only  one  battalion  of  the 
ThirtjT^-fifth  Michigan  Infantry  was  found  to  occupy  a  camp  site 
which  was  rather  low  and  not  well  drained.  Upon  the  recommen- 
dation of  the  board  this  battalion  was  moved  to  higher  ground.  The 
space  allotted  for  regiments  was  ample. 

Water  supply. — Prior  to  the  arrival  of  the  troops  at  this  camp 
several  deep  wells  had  been  bored,  from  which  an  abundance  of  good 
water  was  obtained.  This  was  pumped  into  tanks  of  sufficient  capac- 
ity and  from  these  distributed  through  iron  pipes,  under  constant 
pressure,  to  the  various  regimental  camps.  During  the  first  weeks  of 
the  encampment,  prior  to  the  lajang  of  water  mains,  water  was  hauled 
to  the  regiments  by  water  wagons  and  stored  in  barrels,  but  this  crude 
method  of  water  distribution  was  soon  replaced  by  the  means  above 
described.  These  deep  wells  were  so  situated,  as  regards  regimental 
encampments,  as  to  be  entirely  free  from  any  danger  of  contamina- 
tion from  surface  drainage.  The  supply  of  water,  therefore,  in  this 
encampment  was  abundant  and  of  good  quality. 

Disposition  of  garbage  and  excreta. — Garbage  was  deposited  in  open 
pits  and  frequently  covered  with  earth,  or  in  a  few  instances,  such  as 
in  the  Second  Tennessee  and  Two  hundred  and  second  New  York 
Infantry,  crematories  were  erected  for  the  destruction  of  solid  gar- 
bage. Excreta  were  deposited  also  in  open  pits.  By  order  of  the 
corps  commander  these  pits  for  garbage  and  excreta  were  placed 
on  the  opposite  side  of  the  regimental  camps  from  that  chosen  for 
the  location  of  kitchens  and  mess  tents,  and  in  every  instance  the 
former  were  removed  to  a  considerable  distance  from  the  company 
tents. 

AVith  regard  to  the  sanitary  condition  of  kitchen  and  company  sinks, 
the  following  is  extracted  from  the  letter  of  the  board  addressed  to 
the  adjutant-general  of  the  Second  Army  Corps  October  8, 1898,  upon 
Ihe  completion  of  our  inspection  of  Camp  Meade: 

The  stringent  oi'ders  of  the  commanding  general  concerning  the  care  of  sinks, 
as  to  individual  and  immediate  covering  of  excreta,  under  the  constant  supervision 
of  sentinels,  has  led  to  the  very  good  sanitary  condition  of  the  sinks  of  the  com- 
mand; exceptionally  v^'as  any  fecal  matter  found  uncovered.  In  no  command 
inspected  by  the  hoard  during  the  past  six  weeks  has  an  equally  good  sanitary  con- 
dition of  the  sinks  been  found. 

The  genei*al  police  of  the  regimental  camps  was  excellent. 
Tentage. — This  was  ample  and,  in  addition,  all  tents  were  floored. 


106 

CONSIDERATION  BY  THE  BOARD  OF  TYPHOID  FEVER  IN  THE  FIFTEENTH 
MINNESOTA  INFANTRY. 

Brief  outline  of  ilie  medical  history. — Responding  to  the  second  call 
for  volunteers,  the  Fifteenth  Minnesota  Infantry  assembled  at  Camp 
Ramsey,  the  State  camp,  in  the  fair  grounds  near  St.  Paul,  Minn. ,  the 
first  companies  arriving  there  on  the  5th  of  July,  1898.  The  regiment 
went  into  camp  to  the  east  of  the  race  track  (see  I,  general  sketch 
map  of  Camp  Ramsey),  on  ground  which  had  been  previously  occupied 
by  the  Twelfth  Minnesota,  a  first-call  regiment,  which  had  assembled 
here  the  latter  part  of  April  and  departed  for  the  national  camp  at 
Chickamauga  about  the  16th  of  Ma5^  The  Fifteenth  Minnesota 
remained  on  this  camp  site  until  the  15th  of  August,  when,  in  conse- 
quence of  a  sharp  outbreak  of  typhoid  fever  among  four  companies, 
the  eight  apparently  unaffected  companies  were  removed  to  much 
higher  ground  (see  >To.  Ill  on  the  above-mentioned  map),  while  the 
four  affected  companies  were  shifted  to  new  ground  (see  No.  II  on  map) 
very  near  the  first  site.  The  respective  companies  remained  thus 
encamped  upon  their  new  sites  until  the  23d  of  August,  when,  because 
of  the  development  of  the  epidemic  among  the  eight  companies  orig- 
inally unaffected,  encamped  at  site  No.  Ill  on  the  map,  and  of  the  con- 
tinued spread  of  the  disease  among  the  four  first  affected  companies 
on  site  No.  II  on  the  map,  the  regiment  marched  about  6  miles  to  the 
Government  reservation  at  Fort  Snelling  and  went  into  camp  there. 

Here,  also,  as  a  precaution,  the  four  first  affected  companies  were 
at  first  kept  widely  apart  from  the  other  companies,  but  it  was  soon 
found  that  these  other  companies  were  now  suffering  quite  as  much, 
if  not  indeed  more,  than  the  first  four,  and  at  the  end  of  a  week  after 
moving  to  Fort  Snelling  the  latter  joined  the  camp  of  the  eight  compa- 
nies. Attention  should  be  called  to  the  fact  that  when  the  regiment 
moved  to  Fort  Snelling,  Company  G,  at  that  time  the  only  company 
apparently  unaffected,  was  left  behind  at  Camp  Ramsey  for  a  day  in 
order  to  police  the  abandoned  camp  sites.  The  regiment  now  remained 
encamped  without  further  change  at  Fort  Snelling  until  the  15th  of 
September,  when  it  departed  by  rail  for  the  national  camp  in  Penn- 
sylvania. After  having  been  already  quite  extensively  ravaged  by 
an  epidemic  of  typhoid  fever  which  had  developed  in  its  State  camp, 
the  Fifteenth  Minnesota  arrived  at  Camp  Meade,  the  National  camp 
in  Pennsylvania,  on  the  18th  of  September,  was  assigned  to  the  Third 
Brigade,  First  Division,  of  the  Second  Army  Corps,  and  went  into 
camp  on  high,  rolling,  well-drained  ground.  The  other  regiments  of 
this  brigade  were  the  Eighth,  Twelfth,  and  Thirteenth  Pennsylvania, 
all  from  Camp  Alger,  Va. ,  the  Twelfth  being  temporarily  attached 
under  orders  to  be  mustered  out.  (See  histories  of  these  regiments 
under  Camp  Alger.)  The  Fifteenth  Minnesota  remained  in  Camp 
Meade  without  change  until  the  16th  of  November,  when  it  took  train 
for  Camp  Mackenzie,  near  Augusta,  Ga.,  arriving  at  the  latter  camp 
on  the  18th.  The  regiment  was  still  in  this  camp  on  December  31, 
1898,  and  it  was  there  when  mustered  out  of  service  of  the  United 
States  on  March  27,  1899. 


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107 


The  medical  history,  as  prepared  by  the  board,  covers  a  period  of 
5  months  and  26  days.  Of  this  time,  49  days  were  spent  in  Camp 
Ramsey,  the  State  camp,  near  St.  Paul,  Minn.,  41  of  these  upon  the 
first  camp  site  and  8  upon  the  second  site;  23  days  encamped  upon 
the  Government  reservation  at  Fort  Snelling,  Minn. ;  59  days  at  Camp 
Meade,  the  national  camp  in  Pennsylvania;  33  days  in  Camp  Macken- 
zie, the  national  camp  near  Augusta,  Ga. 

This  regiment  furnishes  a  most  striking  example  of  rapid  prostra- 
tion by  the  ravages  of  typhoid  fever  before  arrival  in  the  national 
camp  of  rendezvous.  Nearly  the  whole  of  its  exceedingly  extensive 
infection  occurred  before  its  arrival  at  Camp  Meade,  Pa.  Indeed, 
there  was  scarcely  any  new  typhoid-fever  infection  after  arrival 
there,  for  nearly  all  the  comparatively  few  cases  developed  in  Camp 
Meade  were  undoubtedly  infected  before  arrival  there.  This  great 
epidemic  was,  therefore,  practically  extinguished  before  the  depar- 
ture of  the  regiment  from  the  national  camp  in  Pennsylvania  for 
the  national  camp  in  the  South. 

With  respect  to  the  origin  of  this  extraordinary  epidemic,  besides 
what  has  already  been  advanced  in  the  foregoing  communications,  it 
may  be  well  to  know  something  of  the  early  history  of  the  Twelfth 
and  Fourteenth  Minnesota  regiments  of  the  first  call,  which  preceded 
the  Fifteenth  at  Camp  Ramsey,  the  Twelfth,  as  already  stated,  having 
previously  occupied  the  same  camp  site.  Although  the  respective 
surgeons  of  these  two  regiments  do  not  admit  the  existence  of  typhoid 
fever  while  at  Camp  Ramsey,  the  details  of  the  medical  histories  of 
these  two  regiments,  as  obtained  by  the  board,  indicate  that  both  the 
Twelfth  and  Fourteenth  Minnesota  regiments  arrived  at  the  national 
camps  in  Chickamauga  Park  already  infected  with  typhoid  fever. 
(See  their  histories  under  Chickamauga  Park. ) 

Develop-ment  of  typhoid  fever  and  related  sickness. — The  following 
is  a  statement,  arranged  in  tabular  form  for  easier  and  more  rapid 
examination  and  classification,  of  fevers  (including  typhoid)  and 
intestinal  disorders  which  have  been  regarded  by  the  board  as  essen- 
tially involved  in  a  just  estimation  of  the  prevalence  of  typhoid  fever. 
In  all  cases  the  dates  given  of  the  beginning  of  attacks  were  recorded 
as  closely  as  they  could  be  ascertained. 

[Mean  strength,  1,280.] 


Intestinal  disorders. 

Febrile  at- 
tacks. 

Typhoid  at- 
tacks. 

Total 
proba- 
ble ty- 
phoid, 
includ- 
ing ma- 
larial. 

Deaths  from 
disease. 

Short, 

1-4 
days. 

Long, 

5-9 
days. 

Pro- 
longed, 
10+ 
days. 

Total 

at- 
tacks. 

Short, 

1-9 
days. 

Long, 
10+ 
days. 

Proba- 
ble. 

Cer- 
tain. 

Ty- 
phoids. 

All 
oth- 
ers. 

July  

August 

September.. 

October 

November . 

67 
140 
63 
43 
12 
8 

333 

3 
31 
JO 
8 
3 
6 

1 
2 

3 
4 

3 

70 
163 

!5 
o5 
17 
14 

1 
270 
136 
6 
1 
1 

1 

387 

160 

19 

8 

3 

17 

33 
7 
2 

33 
65 
44 
14 

2 
6 
5 

1 

5 
11 

3 

Total.. 

50 

13 

394 

146 

14 

48 

415 

477 

18 

108 

A  rectification  of  the  total  number  of  so-called  long  malarias,  as 
given  in  the  above  summary  table,  should  be  made  by  reducing  the 
total  of  14  to  12,  thus  requiring  a  corresponding  reduction  of  the 
number  of  probable  tj^phoid-fever  attacks  from  477  to  475. 

The  above  tabulated  deaths  from  disease,  by  months,  were  distrib- 
uted among  the  companies  as  follows:  Typhoid,  Company  E,  2;  Com- 
pany F,  1;  Company  G,  6;  Company  H,  3;  Company  I,  1;  Company 
K,  1;  Company  L,l;  Company  M,  3;  total,  18.     Other  diseases,  none. 

The  following  is  a  series  of  three  tables,  showing  by  companies, 
respectively,  the  attacks  of  typhoid  fever,  of  so-called  malaria,  etc., 
and  of  intestinal  disorders  in  individuals  (a)  who  have  no  other 
recorded  attacks  (of  the  categories  we  have  been  considering),  and 
(b)  who  have  had  such  other  attacks: 

Intestinal  disorders. 


a^-„„i^     Two      Short 
ol^^V   attacks     and 
^,^0^*     short  !    long 
diar-      diar- 
rhea,     rhea. 


diar- 
rhea. 


Short  -       rn^  !    Pro- 

and  Single  i„Arli'--'  P^O'  'longed 
pro-    I    long    ^f^°^^i longed;    and 

longed  diar-  a^^S  diar-  '■  long 
diar-      rhea.     C^la       rhea.      diar- 


diar- 
rhea. 


diar- 
rhea. 


Total 
diar- 
rhea. 


Company  A. 
Company  B  - 

Company  C  . 
Company  D- 
Company  E  . 
Company  P  . 
Company  G- 
Company  H. 
Company  I. . 
Company  K. 
Company  L  . 
Company  M. 
Ijnassigned  . 

Total  - . 


170 


37 
41 
39 
41 
39 
23 
15 
22 
34 
40 
17 


87 


18 


394 


Total  diarrhea  includes  diarrhea  in  malaria  and  typhoid  combinations. 
Combinations  of  continued  or  malarial  fever. 


Short      ,^^-Z\ai     Long 

malaria  J^^^^lfg,\  malaria 

(uncom-  K'^'-l^fJ^  (uncqm- 


^i-^>-     ^?ht^.^- 


bined). 


T  j     Two 

malaria   i!;**^^?^f 
preceded /°°j|°^/;. 

^'^^^-     diarrnea. 


Total    !    Total 

short    j     long 

malaria,  malaria. 


Company  A. 
Company  B . 
Company  C . 
Company  D. 
Company  E . 
Company  F . 
Company  G. 
Company  H. 
Company  I.. 
Company  K. 
Company  L  - 
Company  M 

Total.. 


103 


8  i  2 
16  1 

13  I  4 

9  1 

14 

12  I 

21  <  1 

13  •  1 
13  1  2 
13  I 

4  I.. 

10 :         2 

146  14 


Totals  include  malaria  in  typhoid  combinations. 


109 

Combinations  of  tyjihoid  fever. 


1 

a 

'o'd 

ft.S 

^^ 

d 

■3 

u 
0 
0 

s 

-d  . 

a 

1° 

0, 

60 

a 
'3  ^ 

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0 
p. 

a 
'So 
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CM 

>, 

-a 
S 

§^ 
^§ 

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0 

P< 
>> 

i 
u 

-^ 

^    ® 

>, 

-d 

(E 

0  s 

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0 

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0 

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0 

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0 

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Company  A  . 
Company  B  . 
Company  C  . 
Company  D  . 
Company  E  . 
Company  P  . 

31 
23 

7 
24 
20 
34 
41 
48 
21 
36 
20 
25 

2 

3 
2 
3 

3 
3 
3 

2 

2 
1 
2 

5 

8 

2 

6 
6 
2 

1 
5 
3 
7 
4 
2 
6 
1 
6 

29 
31 
14 

27 
29 
40 

3 
3 
3 
5 
3 
5 
4 
3 
2 
2 

5 

9 

1 

32 

1 
1 

2 

...... 

1 
I 
1 

2 

2 

34 

i 
1 
•J 

i 
2 

3 

1 



...... 

:::::: 

1 
1 
1 

1 

17 

32 



32 

1 

i 

45 

1         56 

60 

Company  H . 
Company  I  -  - 
Company  K . 
Company  L . 
Company  M. 
Unassigned  . 

59 

62 

25 
46 
21 
36 

2 

27 

3 



48 

26 

1 

'  1 

...... 

2 

2 

45 

3 

Total  -  - 

322 

36 

13 

1 

49 

9 

7 

1         19 

1 

5 

415 

48 

463 

The  records  of  sickness  in  this  regiment  were  found  to  be  more  or 
less  incomplete  and  to  some  extent  conflicting.  By  way  of  illustra- 
tion :  There  are  14  names  of  soldiers  in  this  regiment  in  the  hospital 
records  which  were  not  found  in  the  regimental  sick  report;  and  vice 
versa,  there  are  7  names  of  soldiers  entered  upon  the  regimental 
records  as  having  been  sent  to  the  division  hospital  which  have  not 
been  discovered  in  the  reports  of  the  latter.  Furthermore,  there  are 
9  cases  of  so-called  short  malaria  of  which  there  are  no  final  disposi- 
tions recorded.  How  many  of  these  were  really  typhoid  fever  and 
should  have  been  added  to  the  total  number  of  probable  typhoid  fever 
attacks  given  in  the  above  summary  table  we  could  not  determine. 
That  there  were  some  we  think  can  not  be  reasonably  questioned. 
Moreover,  we  have  encountered  2  fatal  eases  of  typhoid  fever  of 
which  the  only  record  of  sickness  found  was  the  death  return  to  the 
Adjutant-General's  Office.  The  foregoing  tabular  statement  of  sick- 
ness should  be  regarded  as  a  conservative  estimate  of  the  prevalence 
of  typhoid  fever  in  this  regiment. 

The  salient  points  of  the  medical  history  (including  morbidity  and 
mortality)  of  the  Fifteenth  Minnesota  Infantry  as  a  member  of  the 
Third  Brigade  and  First  Division  of  the  Second  Army  Corps,  as  at 
Camp  Meade,  Pa.,  may  be  recapitulated  in  the  following  condensed 
form : 

(a)  The  regiment  was  in  its  State  camp,  in  the  fair  grounds  near 
St.  Paul,  Minn.,  from  July  5  to  August  23,  having  changed  campsite 
August  15;  it  was  on  the  United  States  Government  reservation  at 
Fort  Snelling  from  August  23  to  September  15;  it  was  in  Camp  Meade,, 


110 

the  national  camp  in  Pennsylvania,  from  September  18  to  jSTovember 
16;  it  was  in  the  national  camp  near  Augusta,  Ga.,  from  the  18th  of 
November  until  the  31st  of  December,  1898,  and  it  was  mustered  out 
at  the  latter  place  March  27,  1899.  The  initial  date  of  the  first  prob- 
able attack  of  typhoid  fever  was  July  30 ;  of  the  first  certain  attack 
of  typhoid  fever  was  August  3.  A  quite  sudden  outbreak  of  typhoid 
fever,  at  first  limited  to  certain  companies,  occurred  at  the  State 
camp.  This  caused  first  a  change  of  camp  site  and  soon  after  the 
removal  of  the  regiment  from  the  State  fair  grounds  near  St.  Paul  to 
Fort  Snelling,  but  the  epidemic  assumed  still  larger  proportions  for 
a  while.  Although  by  the  date  of  the  departure  of  the  regiment  for 
the  national  camp  in  Pennsylvania  this  ej)idemic  had  already  begun 
to  rapidly  decline,  it  carried  with  it  the  infection  very  widely  diffused 
among  the  companies.  The  medical  history  as  given  by  the  board 
covers  a  period  of  five  months  and  twentj^-six  days  (from  July  5  to 
the  31st  of  December,  1898),  and  it  is  epitomized  in  the  succeeding 
numerical  data. 

(b)  Attacks  of  intestinal  disorder,  394;  of  so-called  malaise,  short 
malaria,  etc.,  146;  of  so-called  malaise,  long  malaria,  etc.,  12;  of 
probable  typhoid  fever,  48;  and  of  certain  typhoid  fe^er,  415.  Total 
attacks  of  probable  typhoid  fever  (long  malaria,  etc.,  included),  475. 

(c)  Total  deaths  from  typhoid  fever,  18;  total  deaths  from  all 
diseases,  18;  mortality  per  cent  of  total  probable  typhoid  fever 
attacks,  3.78;  of  total  certain  typhoid  fever  attacks,  4.33;  per  cent 
of  total  typhoid  deaths  to  total  deaths  from  all  diseases,  100. 

(d)  The  mean  strength  was  1,280.  The  per  cent  of  typhoid  morbidity 
to  mean  strengh  as  to  total  probable  typhoid  fever  attacks  was  37.10, 
while  the  average  for  the  division  was  22.57;  as  to  total  certain 
typhoid  fever  attacks  was  32.42,  while  the  average  for  the  division 
was  15.42.  The  number  of  typhoid  deaths  per  1,000  of  mean  strength 
was  14.06;  the  average  for  the  division  was  12.55. 

We  have  endeavored  to  ascertain  the  average  age  (in  years)  of  sick 
soldiers,  grouped  by  the  diseases  we  have  been  studying,  as  well  as 
of  soldiers  who  have  died  of  typhoid  fever,  and  we  have  obtained  the 
following  figures  as  to  the  Fifteenth  Minnesota  Infantry: 

(a)  Of  short  intestinal  disorders  in  201  individuals,  average  age. 25. 8 

Of  long  intestinal  disorders  in  22  individuals,  average  age  .-., 25. 2 

Of  prolonged  intestinal  disorders  in  9  individuals,  average  age 21. 8 

Of  the  total  intestinal  disorders  in  232  individuals,  average  age 25. 5 

(6)  Of  short  malaria,  etc. ,  in  60  individuals,  average  age 25. 5 

(c)  Of  long  malaria,  etc.,  in  14  individuals,  average  age 20.9 

Of  probable  and  certain  typhoid  attacks  in  441  individuals,  average  age.  24.0 
Of  total  probable  and  certain  typhoid  and  long  malaria  in  458  individuals, 

average  age .. 23.9 

(d)  Of  grand  total  all  above  classes  in  750  individuals,  average  age 24. 4 

(e)  Of  11  soldiers  who  died  from  typhoid  fever,  the  average  age 24.8 


Ill 

For  comparison  of  these  average  age  figures  with  similar  data  rela- 
tive to  other  regiments  in  the  division^  we  refer  to  the  general  tables 
treating  of  this  subject  at  the  end  of  the  Second  Army  Corps  at  Camp 
Meade,  Pa.  (See,  also,  similar  tables  relating  to  the  regiments  of  the 
Second  Division  of  the  Seventh  Army  Corps  at  Jacksonville,  Fla.) 

Peculiar  hut  general  characteristics  of  company  epidemics  as  exhib- 
ited in  the  graphic  chart. — (a)  It  is  only  when  we  study  the  course  of 
sickness  in  the  regimental  organizations  from  the  standpoint  of  indi- 
vidual companies  that  we  can  adequately  appreciate  the  fact  that  the 
course  of  disease  in  the  regiment  is  characterized  by  a  series  of  com- 
pany epidemics,  each  one  having  more  or  less  perfectly  its  own  indi- 
vidual characteristics.  It  is  especiallj^  true  when  we  regard  the  com- 
mencement, the  exacerbations  during  the  course,  and  the  time  of  the 
termination  of  the  company  epidemics  that  they  are  rarely  seen  to  be 
synchronous.  Not  only  are  there  variations  in  these  company  epi- 
demics considered  as  integral  parts  of  the  regimental  organization, 
but  there  is,  as  a  rule,  no  striking  similarity  in  the  course  of  the  epi- 
demics even  in  the  companies  grouped  together  in  battalion  organiza- 
tions. The  histor}^  of  typhoid  fever  among  the  companies  of  this 
organization  furnishes  more  examples  of  the  exceptions  to  the  general 
rules  just  enunciated  than  perhaps  does  any  other  regiment  in  the 
whole  volunteer  army  which  has  been  studied  by  the  board  from  the 
standpoint  above  mentioned.  This  is  due,  no  doubt,  to  the  fact,  as 
shown  by  the  foregoing  history  of  disease  in  this  regiment,  that  at 
least  four  of  the  companies,  H,  M,  K,  and  F,  inaugurated  the  experi- 
ence of  the  regiment  with  typhoid  fever  by  sudden  and  nearly  simul- 
taneous epidemic  outbreaks  of  the  disease.  Reference  to  the  accom- 
IJanying  diagram  maps  of  the  camps  of  this  regiment  shows  that  these 
companies,  however,  were  in  separate  battalions,  only  two  of  them 
being  adjoining  companies  in  the  middle  battalion;  and  even  in  these 
four  companies  which  had  a  synchronous  beginning  the  subsequent 
course  of  the  disease  was  dissimilar.  While  with  the  four  companies 
mentioned  we  may  assume  that  there  was  a  common  origin  of  the 
epidemics,  we  can  not  infer  the  existence  of  a  common,  simultaneous, 
and  more  or  less  continuously  acting  agency  as  the  chief  means  of 
proi3agation  even  in  these  epidemics.  And  as  to  the  other  companies 
of  this  regiment,  tlie  dissimilarities  in  the  time  of  beginning  and  the 
course  of  the  company  epidemics,  as  well  as  their  ending,  would 
appear  to  be  incompatible  with  the  assumption  of  a  common,  simul- 
taneous, and  more  or  less  continuousl}'^  acting  agency  as  the  chief 
means  of  origin  and  propagation  of  typhoid  fever.  Reference  to  the 
graphic  chart  gives  ample  evidence  of  these  truths,  and  it  is  not 
necessary  to  illustrate  further  hy  entering  into  details. 

(b)  The  company  epidemics  have  frequent  greater  or  less  exacer- 
bations in  their  course,  and  the  intervals  between  these  exacerbations 
are  as  a  rule  closely  coincident  with  the  average  period  of  incubation 


112 

of  typhoid  fever.  A  close  examination  from  this  standpoint  of  the 
foregoing  tabular  statement  and  of  the  graphic  chart  will  more  or  less 
definitely  substantiate  this  statement.  The  truth  of  it  becomes  espe- 
cially evident  if,  instead  of  recording  the  course  of  typhoid  fever  by 
Arabic  numerals  in  the  foi-egoing  tabular  form,  we  indicate  each  indi- 
vidual attack  by  a  dot  corresponding  to  the  proper  date. 

Special  characteristics  of  company  epidemics  from  tJie  standpoint  of 
loccd  or  peculiar  influences. — («)  Reference  to  our  first  diagram  map 
representing  the  first  camp  of  the  Fifteenth  Minnesota  Infantry  at 
Camp  Ramsey,  in  the  fair  grounds  near  St.  Paul,  Minu.,  in  which  we 
have  indicated  the  order  and  relation  of  the  different  companies  of 
this  camp,  as  well  as  the  number  of  attacks  of  typhoid  fever  in  the 
various  tents,  will  show  that  the  four  companies,  H,  K,  M,  and  F, 
which  experienced  almost  simultaneously  the  first  sudden  outbreak  of 
typhoid  fever,  were  distributed  among  the  three  battalions,  only  two 
of  them,  K  and  M,  adjoining  each  other  in  the  center  battalion,  while 
Company  F  was  on  the  extreme  eastern  flank  of  the  regiment  and 
Company  H  was  the  comjjany  next  to  the  extreme  western  flank. 
With  reference  to  the  location  of  the  regimental  latrine  it  is  seen  that 
there  is  a  great  diversity  in  the  location  of  these  four  first-aifected 
companies.  Since  there  was  only  one  large  regimental  latrine  for  the 
use  of  all  companies  in  this  camp,  mere  reference  to  the  relative  loca- 
tion of  these  companies  in  the  regimental  camp  and  the  location  of 
the  latrine  some  distance  from  the  extreme  western  flank  of  the  camp 
would  appear  to  be  sufficient  to  cast  in  doubt  any  common  agency  of 
wind  or  flies  playing  a  chief  role  in  the  origin  or  dissemination  of  the 
infection  of  typhoid  fever  throughout  these  companies,  since  neigh- 
boring or  intervening  companies  of  the  battalions  did  not  participate 
in  a  common  experience. 

(5)  Attention  is  called  to  the  fact  that  when  the  regiment  departed 
from  Camp  Ramsey  in  the  fair  grounds  on  August  23  Company  G 
was  left  behind  for  one  day  to  police  the  abandoned  camps,  thii 
companj^  up  to  that  time  having  been  entirely  free  from  serious  dis- 
ease. The  first  outbreak  in  this  company  was  a  severe  one,  occurring 
on  August  25,  followed  by  a  continuance  of  the  severe  epidemic  for 
three  weeks  or  more.  It  may  be  remarked  here  that  this  company 
was  not  mustered  in  until  July  16, 

(c)  It  may  also  be  remarked  that  when  on  August  15,  owing  to  the 
serious  spread  of  typhoid  fever,  the  first  camp  of  the  regiment  ^vas 
abandoned,  the  four  severely  affected  companies,  K,  M,  F,  and  H, 
were  moved  to  new  and  higher  ground  near  the  first  camp;  the  otner 
companies,  at  this  time  little  affected,  were  moved  to  a  new  site  at  a 
considerable  distance  on  new  and  high  ground,  still  within  the  fair 
grounds  near  St.  Paul.  When  on  August  23  the  regiment  was  moved 
from  Camp  Ramsey  to  Fort  Snelling,  Minn. ,  the  badly  affected  com- 
panies, K,  M,  F,  and  H,  were  placed  in  an  isolated  camp  some  2 


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113 

miles  from  the  general  camp  at  Fort  Snelling  for  about  six  days,  after 
whicli  time  they  joined  the  camp  of  the  regiment,  because  of  the  fact 
that  the  infection  had  by  that  time  become  very  generally  dissemi- 
nated among  the  other  companies. 

Special  characteristics  of  certain  company  epidemics  as  exhibited  by 
general  limitation  of  sickness  to  certain  squads  of  men  as  they  were 
grouped  in  tents,  viewed  from,  the  standpoint  of  a  possible  tent,  squad, 
or  co77irade  infection. — (a)  We  have  endeavored  to  ascertain  the  names 
of  soldiers  as  they  were  grouped  in  their  tents  during  the  periods  of 
encampment  of  this  regiment  at  the  State  fair  grounds  near  St.  Paul, 
and  at  Fort  Snelling,  Minn.,  as  well  as  at  Camp  Meade,  Pa.,  in  order 
to  examine  into  this  important  question.  To  this  end  we  have 
requested  such  data  from  two  different  sources,  namely,  from  the 
regimental  surgeon  and  from  the  commanding  officers  of  the  comj)a- 
nies.  The  regimental  surgeon  in  response  to  this  request  furnished  a 
diagram  map  of  the  camps  of  the  Fifteenth  Minnesota,  in  which  the 
number  of  attacks  of  typhoid  fever  in  individual  tents  of  companies 
was  indicated.  He  also  furnished  a  list  of  names  of  the  men  of 
each  company  as  they  were  grouped  together  in  their  tents.  With 
the  data  thus  obtained  we  have  constructed  two  diagram  maps,  show- 
ing the  order  and  relationship  of  the  companies  in  their  camps  and 
the  number  of  cases  of  typhoid  fever  which  developed  during  four 
different  periods.  In  the  first  map  the  attacks  of  typhoid  fever 
up  to  August  15,  when  the  regiment  first  changed  its  camp,  are 
indicated  by  one  sign;  those  occurring  from  August  16  to  23,  on 
which  latter  date  the  regiment  moved  from  the  State  fair  grounds  to 
Fort  Snelling,  by  another  sign.  In  the  second  map  the  attacks  of 
typhoid  fever  in  two  periods  are  represented,  one  sign  representing 
the  period  during  which  the  regiment  was  encamped  at  Fort  Snelling, 
and  the  other  sign  representing  the  last  period,  beginning  when  the 
regiment  reached  the  national  camp,  Camp  Meade,  Pa.,  September  18. 
Reference  to  these  maps  shows  the  manner  in  which  the  attacks  of 
typhoid  fever  were  grouped  with  regard  to  certain  tents.  The  squad 
groups  of  the  sick  as  plotted  in  their  tents  would  seem  to  be  incom- 
patible with  the  assumption  that  the  chief  factor  in  the  propagation 
of  typhoid  fever  throughout  the  companies  of  this  regiment  may  have 
been  some  agency  whose  influence  was  common  and  pretty  constantly 
acting  upon  the  whole  command;  on  the  contrary,  they  would  appear 
10  suggest  a  mode  of  disseminating  infection  which  more  effectively 
reached  and  acted  upon  certain  limited  groups  of  men,  while  it  passed 
by  others,  which  would  be  entirely  compatible  with  the  assumption  of 
a  dominating  tent,  squad,  or  comrade  infection.  Whatever  the  ori- 
gin of  the  epidemic  might  be,  whether  a  water  infection,  for  example, 
which  acted  upon  four  companies  simultaneously  and  not  upon  otlier 
companies  of  the  regiment,  in  the  course  of  the  subsequent  epidemic 
some  other  mode  of  infection  became  dominant  sooner  or  later  and 
7273 8 


114 

gave  rise  to  dissimilarities  even  in  those  companies  where  the  original 
infection  may  have  been  simultaneous. 

(&)  A  further  indication  of  the  existence  and  active  influence  of  a 
tent,  squad,  or  comrade  infection  throughout  this  command  is  the 
following  result  of  a  careful  analysis  we  have  made  of  the  records  of 
sickness  in  this  regiment  in  connection  with  the  grouping  of  infected 
men  in  their  tents  and  the  average  time  elapsing  between  successive 
or  "  connectable "  attaclis  in  the  same  tent  and  in  adjoining  tents. 
As  deduced  from  the  surgeon's  tent  lists,  we  find  that  among  436  cases 
of  typhoid  fever  platted  in  their  respective  tents  317,  or  72.70  per  cent, 
were  separated  or  "  connectable "  b}^  periods  which  could  fairly  be 
regarded  as  measuring  the  average  period  of  incubation  of  typhoid 
fever. 

Estimation  of  the  average  length  of  the  period  of  incubation  of 
typhoid  fever. — We  have  endeavored  to  calculate  the  average  period 
of  incubation  of  this  disease  from  data  obtained  from  two  different 
sources,  and  we  have  found  a  striking  coincidence  in  the  average  of 
the  figures  thus  obtained : 

(a)  Period  of  incubation  as  deduced  from  the  length  of  intervals 
between  "  connectable  "  attacks  of  typhoid  fever  occurring  in  the  same 
or  in  adjoining  tents.  As  deduced  from  the  surgeon's  tent  lists  among 
436  attacks  of  typhoid  fever  as  plotted  in  their  respective  tents,  there 
were  214  intervals  between  attacks  which  could  fairly  be  regarded  as 
measuring  the  length  of  an  average  period  of  incubation.  The  aver- 
age lengths  of  these  214  intervals  was  10.2  days. 

(6)  Period  of  incubation  as  deduced  from  the  length  of  intervals 
between  attacks  of  diarrhea  preceding  typhoid  fever  and  the  develop- 
ment of  the  typhoid  fever  attacks.  The  Fifteenth  Minnesota  furnished 
2G  examples  of  attacks  of  diarrhea  preceding  typhoid  fever  by  periods 
which  could  fairly  be  regarded  as  measuring  a  period  of  incubation. 
The  length  of  the  intervals  in  these  cases  averaged  11.7  days. 

]Sr.  B. — For  similar  data  concerning  other  regiments  of  this  corps 
and  of  the  regiments  of  the  Second  Division,  Seventh  Army  Corps, 
see  tables  relating  to  this  subject  under  the  respective  corps. 

Average  length  of  disability  from  typhoid  fever. — The  fullness  and 
completeness  of  the  records  concerning  typhoid  fever  in  the  Fifteenth 
Minnesota  Infantry  furnished  an  opportunity^  for  an  endeavor  to  ascer- 
tain the  average  length  of  disability  from  tj^'phoid  fever  in  a  military 
command  in  active  service  in  the  field.  An  analysis  of  326  cases,  of 
which  the  records  were  complete — that  is,  the  lapse  of  time  between 
the  recorded  beginning  of  the  attack  and  the  date  of  return  to  duty — 
shows  the  average  to  be  66  days.  These  326  cases  were  distributed 
as  follows:  First  class  comprised  179  attacks  occurring  anterior  to 
the  25th  of  August  (ten  daj^s  after  the  removal  of  the  regiment  from 
its  first  camp  site).  The  average  disability  in  this  class  was  70  days. 
Second  class,  attacks  occurring  between  August  26  and  September  3 
(ten  days,  respectively,  after  the  commencement  and  end  of  the  sec- 


115 

ond  camp  at  Camp  Ramsey).  Seventy-seven  attacks  occurred  during 
this  period  which  averaged  64  days  of  disability.  Third  class,  Sep- 
tember 4  to  September  29  (ten  days,  respectively,  after  the  commence- 
ment and  end  of  the  regiment's  encampment  at  Fort  Snelling) .  This 
period  embraced  66  attacks  of  typhoid  fever  whose  average  disabilitj^ 
was  67  days  each.  Fourth  class,  after  September  29  (ten  days  after 
the  arrival  of  the  regiment  at  the  national  camp  at  Camp  Meade). 
This  period  embraced  4  cases,  whose  disabilitj^  averaged  each  42  days. 
It  is  thus  seen  that  the  length  of  average  disability  was  much  shorter 
in  those  cases  infected  in  the  national  camp  than  in  the  cases  infected 
in  earlier  camps.  (See  also  general  table  relating  to  this  matter 
under  the  Second  Army  Corps  at  Camp  Meade.) 

In  this  regiment  (the  Fifteenth  Minnesota)  the  average  length  of 
disability  caused  by  typhoid  fever  attacks  was  ascertained  in  326 
■cases.     These  cases  are  considered  under  four  groups  or  classes,  viz : 

1.  Attacks  which  occurred  before  August  25 .  _ .    _ . . 179 

2.  Attacks  which  occurred  from  August  26  to  September  3 77 

3.  Attacks  which  occurred  from  September  4  to  29 66 

4.  Attacks  which  occurred  after  September  29 4 

Total - 326 

Average  days  of  disability  in  group  1 .-  -  70 

Average  days  of  disability  in  group  2 64 

Average  days  of  disability  in  group  3. 67 

Average  days  of  disability  in  group  4 -.- 42 

Average  days  of  disability  in  all  four  groups 68 

The  instances  in  which  3  or  more  typhoid  attacks  occurred  in  the 
same  tent  were  81,  distributed  in  the  four  groups  as  follows: 

1.  Attacks  whi  ch  occurred  before  August  25  . .  - .  42 

2.  Attacks  which  occurred  from  August  26  to  September  8 22 

3.  Atttack  which  occurred  from  September  4  to  29 ...  15 

4.  Attacks  which  occurred  after  September  29 2 

Total - 81 

Average  of  days  of  disability  in  group  1 70 

Average  of  days  of  disability  in  group  2.. '67 

Average  of  days  of  disability  in  group  3 69 

Average  of  days  of  disability  in  group  4 ...  46 

Average  of  days  of  disability  in  all  four  groups 68 

CONSIDERATION    BY   THE    BOARD    OF   TYPHOID    FEVER   IN    THE    FOURTH 
NEW   JERSEY   INFANTRY. 

Brief  oidline  of  the  ■medical  history. — This  is  a  second-call  regiment 
which  assembled  and  was  mustered  at  the  State  camp  by  the  shore  of 
the  sea  at  Seagirt,  N.  J.,  on  the  19th  of  July,  1898,  and  remained 
encamped  there  until  the  8th  of  October,  on  which  latter  date  it  started 
by  rail  for  the  national  camp  near  Middletown,  Pa.  The  next  day  the 
command  reached  Camp  Meade,  Pa.,  was  assigned  to  theFirstBrigade, 
Second  Divisionof  the  Second  Army  Corps,  as  at  Camp  Meade,  and  went 
into  camp  with  the  Two  hundred  and  third  New  York  and  Second  West 

I 


116 

Virginia,  the  two  other  members  of  this  brigade  which  came  direct  to 
Camp  Meade  from  their  respective  State  camps.  It  should  be  remarked 
that  the  Two  hundred  and  third  New  York  had  already  been  removed 
to  an  isolation  camp  8  miles  away  before  the  arrival  of  the  Fourth 
New  Jersey.  (See  history  of  the  Two  hundred  and  third  New  York. ) 
The  One  hundred  and  fifty-ninth  Indiana,  Twenty-second  Kansas, 
Third  New  York,  and  Eighteenth  Pennsylvania  were  for  a  time 
attached  to  the  same  brigade,  under  orders  to  be  mustered  out.  (See 
histories  of  these  regiments  under  Camp  Alger.)  The  Fourth  New 
Jersey  remained  at  Camp  Meade,  Pa.,  until  the  12th  of  November, 
when  it  left  by  rail  for  Camp  Wetherill,  near  Greenville,  S.  C,  where 
it  arrived  on  the  14th.  It  was  still  at  Camp  Wetherill  on  the  31st  of 
December,  1898,  and  was  mustered  out  of  the  service  of  the  United 
States  on  the  6th  of  April,  1899,  at  Greenville,  S.  C. 

The  medical  history  of  this  regiment  as  prepared  by  the  board  cov- 
ers a  period  of  five  months  and  twelve  days.  Of  this  time  eighty-one 
days  were  spent  in  the  State  camp  at  Seagirt,  N.  J.,  thirtj^-four  days 
at  the  national  camp,  near  Middletown,  Pa. ,  and  forty-seven  days  in 
Camp  Wetherill,  near  Greenville,  S.  C. 

In  his  testimony  before  the  board  the  surgeon  in  charge  of  the  regi- 
ment admits  the  development  of  a  case  of  typhoid  fever  two  days 
after  the  arrival  of  the  regiment  at  Camp  Meade,  the  first  case  of  the 
disease  recognized  as  such  by  him.  This  case  was  of  course  infected 
some  days  before  the  arrival  of  the  command  at  the  national  camp  in 
Pennsylvania.  Moreover,  an  examination  of  the  following  details  of 
sickness  in  this  regiment  abstracted  from  the  available  records  shows 
that  there  were  4  attacks  regarded  by  the  board  as  probably  typhoid, 
which  developed  respectively  on  the  2d,  7th,  24th,  and  28th  of  Sep- 
tember. In  connection  with  these  4  September  attacks  it  should  be 
remembered  that  about  the  last  of  August  the  First  New  Jersey 
returned  to  its  State  camp  at  Seagirt  from  Camp  Alger,  Va.,  with  20 
soldiers  suffering  from  typhoid  fever,  and  that  about  the  25th  of  Sep- 
tember the  Second  New  Jersey  returned  to  the  same  State  camp  from 
the  national  camj)  at  Jacksonville,  Fla.,  suffering  greatly  from  typhoid 
fever  and  carrying  with  it,  according  to  the  surgeon  of  the  Fourth 
New  Jersey,  60  cases  of  typhoid  fever  and  leaving  behind  in  Florida 
as  many  more  sick  in  hospital.  The  Second  New  Jersey  adjoined  the 
Fourth  New  Jersey  in  the  State  camp  and  the  men  of  all  three  regi- 
ments freely  intermingled.  Prior  to  the  return  of  the  First  New  Jer- 
sey and  Second  New  Jersey  from  the  respective  national  camps  where 
they  "had  become  infected  with  typhoid  fever  it  is  probable  that  there 
was  no  such  infection  in  the  State  camp  at  Seagirt,  unless  indeed  we 
may  suspect  that  a  case  of  continued  fever  developing  on  the  2d  of 
August  in  the  Fourth  New  Jersey  was  really  a  typhoid  attack  rather 
than  of  malarial  character,  as  diagnosed  by  the  surgeon.  Whether 
the  typhoidal  infection  certainly  existing  in  the  Fourth  New  Jersey 
anterior  to  its  arrival  at  Camp  Meade  was  indirectly  chargeable  to 


117 


camps  Alger  and  Cuba  Libre,  or  developed  independent  of  that  exist- 
ent source  of  infection,  this  regiment  must,  in  view  of  the  foregoing, 
be  classed  with  those  which  have  brought  from  their  State  camps  the 
infection  of  typhoid  fever.  Carrying  with  it  into  the  national  camp 
the  infection  of  tj^phoid  iever,  the  Fourth  New  Jersey  presents  one  of 
the  very  few  examples  in  this  whole  campaign  of  a  regiment  having 
started  with  the  infection  yet  escaping  the  subsequent  development 
of  an  epidemic  of  typhoid  fever. 

Development  of  typhoid  fever  and  related  sickness. — The  folio  wing- 
is  a  statement  arranged  in  tabular  form  for  the  easier  and  more 
rapid  examination  and  classification  of  fevers,  including  typhoid, 
and  intestinal  disorders  which  have  been  regarded  by  the  board  as 
essentially  involved  in  a  just  estimation  of  the  prevalence  of  typhoid 
fever.  In  all  cases  the  dates  of  the  beginning  of  attacks  were  recorded 
as  closely  as  they  could  be  ascertained : 

[Mean  strength,  1,225.] 


Intestinal  disorders. 

Febrile  at- 
tacks (malaria, 
etc). 

Typhoid  at- 
tacks. 

Total 
prob- 
able 
ty- 
phoid 
includ- 
ing ma- 
laria. 

Deaths 
from 

disease. 

Short, 

1-4 
days. 

Long, 

5-9 
days. 

Pro- 
longed, 
10-1- 
days. 

Total 

at- 
tacks. 

Short, 

1-9 
days. 

Long, 
10 -f- 
days. 

Prob- 
able. 

Cer- 
tain. 

2 

"o 

ft 

s 

si 
< 

July      

29 
35 
45 
39 
5 
19 

1 
4 
6 
5 
1 

2' 

1 

1 

30 
39 
51 

46 

7 

20 

2 
13 
5 
3 
3 

August 

1 

i" 

1 

4 
4 
4 

September 

3 
1 
2 

2 
2 
2 

October 

November 

December 

Total.— 

172 

17 

4 

193 

26 

3 

5 

6 

13 

2 

Two  "  other  deaths  "  in  February,  1899.    No  typhoid  deaths. 

MALARIAL  DISEASES  AT  CAMP  MEADE,  PA. 

With  regard  to  the  prevalence  of  malarial  fevers  at  this  camp, 
we  may  state  that  having  followed  with  much  care  the  cases  of  mala- 
rial fe^er  reported  by  the  medical  officers  of  the  thirteen  regiments 
whose  histories  are  here  given,  we  have  found  the  diagnosis  in  a  large 
majority  of  cases  admitted  to  division  hospitals  afterwards  changed 
to  that  of  typhoid  fever.  Tliis  would  appear  to  indicate  that  malarial 
fevers  were  not  prevalent  at  Camp  Meade.  Concerning  this  matter 
Acting  Asst.  Surg.  George  Dock,  who  visited  this  camp  during  the 
tliird  week  in  September  for  the  purpose  of  making  blood  examina- 
tions, says: 

When  I  arrived  at  Camp  Meade  I  found  comparatively  few  cases  with  the  diag- 
nosis of  malaria  in  the  Second  Division  hospital.  Most  of  the  surgeons  claimed 
that  malarial  disease  was  very  rare  there.  I  found  two  wards,  the  so-called  mala- 
rial wards  (3  and  4).  in  which  a  great  many  cases  had  the  diagnosis  of  malaria. 
I  examined  the  blood  of  many  of  these,  also  of  many  recently  admitted  men  and 
some  suspicious  cases  in  other  wards,  to  the  number  of  20,  but  without  find- 
ing any  parasires.  As  the  bacteriological  outfit  was  incomplete,  Widal  tests 
could  not  be  made,  but  out  of  the  so-called  malarial  cases  at  least  two-thirds  were 


118 

evidently  typhoid  in  the  middle  stage,  some  not  yet  definitely  recognizable,  and 
some  convalescent. 

In  the  first  division  hospital  I  was  told  there  were  a  great  many  cases  of  malaria 
and  typho-malarial  fever.  Several  so-called  typical  cases  of  the  latter  had  nO' 
parasites,  and  were  evidently  uncomplicated  cases  of  typhoid  fever.  One  case 
proved  to  be  malaria,  and  is  quite  as  instructive  as  the  positive  case  found  at 
Chickamauga.  Private  B,  Company  F,  Fifteenth  Pennsylvania  Infantry,  came- 
two  weeks  before  examination  from  Sheridan  Point  on  the  Potomac  River.  Four 
days  later  he  began  to  have  chills,  and  had,  so  far  as  he  knows,  three  chills.  He 
felt  quite  well  the  free  days.  The  temperature  had  not  been  taken  often  enough 
to  give  the  type.  There  had  been  a  chi  1  the  day  before  examination,  and  the 
patient  had  taken  24  grains  of  quinine  in  two  days.  Soon  after  beginning  the 
examination  I  found  an  organism  almost  filling  a  red  blood  corpuscle. 

Like  the  case  previously  described,  at  Chickamauga.  he  came  to  camp  already- 
infected.  To  summarize:  I  found  renaarkably  little  evidence  that  malaria  was- 
prevalent  in  Camp  Meade,  the  only  case  found  being  imported. 

The  evidence  of  so  competent  an  observer,  based  on  blood  examina- 
tions made  at  Camp  Meade,  is  of  great  importance  in  determining  the 
slight  part  which  malaria  played  as  a  factor  in  the  fevers  at  this  camp. 
We  have  been  inclined  to  look  upon  many  of  these  short  (less  than 
ten  days)  fevers,  of  supposed  malarial  character,  as  really  cases  of 
mild  infection  with  the  typhoid  bacillus. 

We  have  already  given  the  result  of  our  investigations  bearing  on 
this  point  in  nineteen  regiments  of  the  Second  Army  Corps,  at  Camp 
Alger,  Va.  We  have  repeated  the  same  patient  investigation  of  the 
subsequent  history  of  all  of  these  supposed  malarial  fevers  in  thirteen 
regiments  of  this  corps  at  Camp  Meade,  Pa.,  in  order  to  ascertain 
whether  these  men  possessed  a  relative  immunity  to  typhoid  fever  as- 
compared  with  those  men  who  did  not  experience  these  milder  fevers. 
The  results  are  given  in  the  following  table : 


Cases  of  typhoid  fever  among  men  with  and  toithout  j^receding  malarial  diseases 
in  thirteen  regiments  Second  Army  Corps,  at  Camp  Meade,  Pa. 


Regiment. 


Cases 
of  ma- 
laria. 


Cases  of  malaria 

followed  by 

typhoid  fever. 


Num-  ,    In  100 
ber  of  I  malarial 
cases.      cases. 


Number 
of  men 
without 
preced- 
ing ma- 
laria. 


Typhoid  cases 
without  preced- 
ing malaria. 


Num- 
ber of 
cases. 


In  100 
men  who 
have  not 
had  ma- 
laria. 


Total 
cases 
of  ty- 
phoid 
fever. 


3d   Connecticut 1,214 

1st  Delaware 926 

1st  Maryland 1,2.51 

.oth  Massachusetts. 1.275 

3.5th  Michigan _.  1,1.50 

1.5th  Minnesota 1,280 

4th  New  Jer.sey 1,22.5 

201st  New  York 1,076 

202d    New  York 1,125 

203d    New  York 1,047 

loth  Ohio 1,288 

2d     Pennsylvania 1, 070 

2d     West  Virginia 1,165 


Total _-_ 1,5,092       1,430 


39 
70 
41 
108 
171 
112 
23 
196 
222 
153 
157 
54 


3.5 


6.7 

4.5 

17.0 

5.1 


8.3 


1,175 

856 

1,210 

1,167 

979 

1, 168 

1,202 

880 

903 

894 

1, 131 

1,016 

1,081 


152 

43 

85 

53 

313 

463 

11 

160 

140 

454 

253 

5 

173 


12.9 

5.0 

7.0 

4.5 

31.9 

39.6 

.9 

18.3 

15.5 

50.8 

23.4 

.5- 

16.0 


152- 
45. 
85 
.53 
319 
463: 
11 

178; 

1.50 
480 
261 
5- 
180 


72 


5.0 


13,662       3,305         16.9 


3,377- 


That  is:  Of  1,4.30  individuals  who  were  treated  for  malaria  72,  or  5  per  cent,  subsequentljr 
had  typhoid  fever. 
Of  13,662  men  who  were  not  treated  for  malaria  2.305,  or  16.9  per  cent,  had  typhoid  fever. 
Or:  Of  2,377  cases  of  typhoid  fever  73,  or  o  per  cent,  had  previously  been  treated  for  malaria. 
Of  3,377  cases  of  typhoid  fever  3,305,  or  97  per  cent,  had  no  preceding  malaria. 


119 

We  therefore  conclude  that  malarial  diseases  were  rare  at  Cami) 
Meade,  and  that  a  majority  of  the  milder  fevers,  so  designated,  were 
really  manifestations  of  infection  with  typhoid  bacillus. 

THE    RELATION    OF   INTESTINAL   DISORDERS   TO    TYPHOID    FEVER. 

We  have  given,  under  the  Second  Army  Corps,  at  Camp  Alger,  Va., 
the  result  of  our  investigations  Avith  regard  to  the  predisposition  to 
typhoid  fever  which  intestinal  disorders  are  supposed  to  favor.  We 
have  there  drawn  the  conclusion  that,  contrarj^  to  the  generally 
accepted  opinion,  these  intestinal  disorders  not  only  do  not  favor  the 
development  of  tyx3hoid  fever  in  the  affected  individuals,  but  that 
they  bring  about  a  relative  immunity  to  typhoid  attacks.  The  fol- 
lowing table  will  show  that  the  same  conclusion  can  be  drawn  from 
our  investigations  at  Camp  Meade : 

Cases  of  typhoid  fever  among  men  with  and  without  %>receding  diarrheal  diseases 
in  the  thirteen  regiments  of  the  Second  Army  Corps,  at  Camp  Meade,  Pa. 


? 

01 

S 

CD 

Cases  of  diar- 
rheal diseases. 

Cases    of  diar- 
rhea followed  by 
typlioid  fever. 

Num- 
ber of 
men 
with- 
out 
preced- 
ing 
diar- 
rhea. 

Typhoid  fever 
cases  without 
preceding  diar- 
rhea. 

Total 
cases 

Regiment. 

Num- 
ber of 
cases. 

Num- 
ber of 
indi- 
vidu- 
als. 

In  100 
Num-  '     men 
ber  of  witlipre- 
cases.     ceding 
diarrhea. 

Num- 
ber of 
cases. 

In     100 
men  not 

having 

had  diar 

rhea. 

of  ty- 
phoid 
fever. 

3d  Connecticut 

1,214 
926 
1,251 
1,275 
1,150 
1,2S0 
1,225 
1.076 
1,125 
1,047 
1,288 
1,070 
1.165 

35 

49 

27 

205 

188 

346 

168 

198 

109 

162 

318 

236 

7 

35 

48 
24 
190 
178 
291 
152 
188 
100 
151 
286 
207 
7 

5        14.3 

1.179 
878 

1,227 

1,085 
972 
989 

1,073 
888 

1,025 
896 

1,002 
863 

1,158 

147 
45 
84 
49 
304 
427 
10 
1.52 
144 
433 
219 
4 
180 

12.5 

5.1 

6.8 

4.5 

31.3 

43.2 

.9 

17.1 

14.0 

48.3 

153 

45 

1st  Maryland 

5th  iVIassachiTsetts 

:i5th  Michigan 

15th  Minnesota 

4th  New  .Tersey 

201st  New  York 

1 

4 
15 
36 

1 
21 

6 

47 

42 

,       1 

4.2 

2.1 

8.4 

12.4 

.6 

11.2 

6.0 
31.1 
14.7 
.5- 

85 
53 
319 
463 
11 
173 

202d  New  York 

150 

203d  New  York       

480 

10th  Ohio - - 

21.85  1      26i 

2d  Pennsylvania 

2d  West  Virginia 

.46           5 
15.5     1      ISO 

2.377 

Total 

15,092 

2,048 

1,8.57 

179 

9.1 

13,235 

2, 198 

16.6 

That  is:  Of  1,857  individuals  who  were  treated  for  intestinal  complications  179,  or  9.1  per  cent, 
subsequently  had  typhoid  fever. 

Of  13.235  men  who  had  not  been  treated  for  intestinal  complications,  3,198,  or  16.6  per  cent,  had 
typhoid  fever. 

Or:  Of  2,377  cases  of  typhoid  fever,  179.  or  7.5  per  cent,  had  previously  been  treated  for  diar- 
rhea. 

Of  2,377  cases  of  typhoid  fever,  2,198,  or  92.5  per  cent,  had  no  previous  intestinal  complications. 


ORIGIN   AND    SPREAD    OF    TYPHOID    FEVER   IN    THE    SECOND    ARMY 
CORPS    AT    CAMP   MEADE,  PA. 

Eveiy  regiment  that  arrived  at  this  national  camp,  whether  coming 
from  another  general  encampment,  such  as  Camp  Alger,  Va.,  or  direct 
from  State  cami3S,  imported  typhoid  fever.  There  was  no  exception 
to  this  general  statement.  Of  25  regiments  that  reached  this  camp 
during  the  latter  half  of  August  and  the  first  half  of  September,  18 
were  thoroughlj^  infected  with  typhoid  fever  and  7  had  already  had 


120 

from  2  to  8  cases  of  this  disease.  The  origin  of  typhoid  fever  at  Camp 
3Ieade  is  therefore  clear. 

For  the  course  of  the  disease  in  the  several  organizations  during 
the  period  August  15  to  iSTovember  15,  1898,  the  period  of  occupancy 
of  Camp  Meade,  the  regimental  history  and  the  graphic  charts  should 
be  consulted.  From  a  studj"  of  these  it  will  be  seen,  as  we  have 
already  repeatedly  had  occasion  to  remark  in  our  summary  of  regi- 
mental histories,  that  typhoid  fever  at  Camp  Meade,  as  elsewhere, 
consisted  essentially  of  a  series  of  company  epidemics,  each  one 
having  more  or  less  perfectly  its  own  individual  characteristics.  The 
dissimilarities  in  the  time  of  beginning  and  the  course  of  the  company 
epidemics,  as  well  as  their  ending,  would  appear  to  be  incompatible 
with  the  assumption  of  a  common,  simultaneous,  and  more  or  less 
continually  acting  agency  as  the  chief  means  of  origin  and  propaga- 
tion of  typhoid  fever.  Reference  to  the  graphic  charts  gives  ample 
evidence  of  these  truths,  and  it  is  not  necessary  to  illustrate  further 
by  entering  into  details.  The  course  of  typhoid  fever  in  the  various 
companies  forming  the  regiments  of  the  First  and  Second  Divisions  of 
the  Second  Army  Corps  at  Camp  Meade,  Pa.,  was  such  as  to  conclu- 
sively eliminate  any  contamination  of  the  general  or  company  water 
supply. 

We  have  already  shown  in  the  case  of  the  Thirty-fifth  Michigan, 
Fifteenth  Minnesota,  and  Two  hundred  and  third  New  York  Infantry 
the  result  of  our  endeavors  to  ascertain  the  names  of  soldiers  devel- 
oping typhoid  fever  as  they  were  grouped  in  their  tents  in  the  several 
camps.  (For  details  see  histories  of  these  regiments.)  Reference  to 
the  diagrams  accompanying  these  regiments  will  show  the  manner  in 
which  the  attacks  of  tj^phoid  fever  were  grouped  with,  regard  to  cer- 
tain tents.  These  squad  groups  of  the  sick,  as  plotted  in  their  tents, 
would  appear  to  suggest  a  mode  of  disseminating  infection  which 
effectively  reached  and  acted  upon  certain  limited  groups  of  men 
w^hile  it  passed  by  others.  This  would  be,  we  think,  entirelj^  com- 
patible "svith  the  assumption  of  a  dominating  tent,  squad,  or  comrade 
infection.  This  would  seem  to  hold  true  of  any  company  epidemic 
which  persists  for  any  considerable  time,  whatever  may  have  been 
the  mode  of  the  original  infection.  We  have  already  stated  under 
the  head  of  general  remarks  that  the  general  police  of  the  regimental 
camp  sites  was  excellent,  and  that  the  care  of  the  company  sinks,  as 
regards  the  immediate  covering  of  all  excreta,  was  very  satisfactory. 
We  do  not  doubt  that,  notwithstanding  these  sanitarj'  precautions, 
there  were  individual  instances  of  what  we  have  designated  as  sink 
infection,  or  that  food  was  occasionally  infected  by  flies.  We  believe, 
however,  that  squad  or  comrade  infection  was  probably  the  most 
important  factor  concerned  in  the  spread  of  typhoidfever  at  Camj) 
Meade,  Pa. 


121 


General  table  showing  number  and  per  cent  of  connectable  typhoid  attacks  in  tents 
(as  deduced  from  surgeons'  tent  lists)  in  three  regiments  of  the  Second  Army 
Corps  at  Camp  Meade,  Pa. 


Di- 

Per 

Indi- 

Per 

Per 

Grand  total. 

rectly 

cent of 

rectly 

cent  of 

Regi- 

cent of 

Num- 

Per 

cent  of 

At- 
tacks 
plot- 
ted. 

con- 

con- 

con- 

con- 

mental 

con- 

ber of 

necta- 

necta- 

necta- 

necta- 

totals 

necta- 

con- 

Regiment. 

ble  at- 

ble to 

ble  at- 

ble to 

(direct 

ble  to 

necta- 

necta- 
ble  to 
all  at- 
tacks 
plotted 

tacks 

all  at- 

tacks 

all  at- 

and in- 

all at- 

ble at- 

(in 

tacks 

(in 

tacks 

di- 

tacks 

tacks 

same 

plot- 

next 

plot- 

rect). 

plot- 

of 

tents). 

ted. 

tents). 

ted. 

ted. 

those 
plotted 

189 
436 
467 

59 
199 
106 

31.31 
4.5. 64 
33.69 

65 
118 
138 

34.39 
37.06 
37.41 

134 
317 
234 

65.60 

72.70 
50.10 

2()3d  New  York 

1,093 

364 

33.33  1        311 

38.48 

675 

61.81 

Table  shoicing  number  and  per  cent  of  connectable  typhoid  fever  attacks  in  tents 
{as  deduced  from  captains'  tent  lists)  in  certain  companies  of  two  regiments  of 
the  Second  Army  Corps  at  Camp  Meade,  Pa. 


i 
p, 
a 

o 
O 

At- 
tacks 
plot- 
ted. 

Di- 
rectly 

con- 
necta- 
ble at- 
tacks 
in  same 
tents. 

Per 
cent  of 

con- 
necta- 
ble to 
all  at- 
tacks 
plot- 
ted. 

Indi- 
rectly 

con 
necta- 
ble  at- 
tacks 
in  next 
tents. 

Per 
cent  of 

con- 
necta- 
ble to 
all  at- 
tacks 
plot- 
ted. 

Company 
totals  (direct 
and  indirect). 

Regimental 
totals. 

Regiment. 

Num- 
ber of 
con- 
necta- 
ble at- 
tacks. 

Per 

cent  of 
con- 
necta- 
ble to 
all  at- 
tacks 
plot- 
ted. 

Num- 
ber of 
con- 
necta- 
ble at- 
tacks. 

Per 
cent  of 
con- 
necta- 
ble to 
all  at- 
tacks 
plot- 
ted. 

A 
L 

45 
29 

33 

7 

51.11 

34.13 

13 

8 

38.89 
27.50 

36 
15 

80.00 
.51. 73 

Total-- 

74 

51 

68.91 

A 
C 
K 

303d    New  York      . 

61 
45 

48 

37 
16 
19 

44.36 
35. 55 
39.58 

17 
10 
13 

37.85 
33.32 
3.5.00 

44 
36 
31 

73.13 
57.  77 
64.58 

Total 

154 

101 

65.58 

328 

92 

4C.35 

60 

36.31 

152 

66.66 

General  table  showing  average  interval  between  connectable  typhoid  fever  attacks  in 
tents  (as  deduced  from  surgeons'  tent  lists)  in  three  regiments  of  the  Second 
Army  Corps  at  Camp  Meade,  Pa. 


'6 
o 

o 
p. 

03 

1 

'O   =°   73 

o  a,  c 

u  o  S 
22ce 

s 

I—) 

a 
'R  ■ 

03  m 

05  03 

^^ 
CO   C8 

&^ 

a;  ce 

CS  o 
MOJ 
0,  0 

^  a 

boo 
iUJO 

< 

PI 

<D   CC 

111 

(B  O 

■^  a 

.9  e8 

05 

|8S 

<s   . 

05  to 

ID  ce 

^^ 

05  CS 

rf  o 

05  a 
'-  d 

MO 
Saoo 

PI 

05     . 

II 
II 

Si 

05  U 

cS  PI 

tH  a 

05  O 

o 

4J 

05 

a 
a 

05 

Pi 
f» 

^1 

^05 

05^ 

c3  o 
61)05 

OJ  pt 
t-t  d 

6jCO 

H 

n 

05  O 
61)05 

05  O 

Grand  totals. 

Regiment. 

01  O 
[>  05 

U  d 

9  0,^ 
-^  o  to 

P  c^ 
-i-i        o 

^%^ 
XJ  tS  05 

a^3 

pl,P  cS 

i5 

t0  4J 

05  o 
ti  O  to 

6t^S 

< 

to'o 

l>)05 

^  '^  to 
P  05  °3 

< 

35th  Michigan 

15th  Minnesota 

189 
436 
467 

33 
118 
56 

334 

1,194 

606 

10.1 
10.1 
10.8 

45 
98 
86 

442 

987 
873 

9.8 
10.3 
10.1 

78 
814 
143 

776 
2,181 
1,479 

9.9 
10.2 
10.4 

203d    New  York   . . 

Grand  total- . 

1,092 

307 

2,134 

10.3 

327 

3,303 

10.1 

434 

4,436 

10.2 

122 

Table  shoiving  average  interval  hetioeen  typhoid  attacks  in  tents  {as  deduced  from 
captains'  lists)  in  certain  companies  of  tivo  regiments  of  the  Second  Army  Corps 
at  Camp>  Meade,  Pa. 


n 

a 

o 
O 

1 
P. 

o 

< 

O    ^ 

II 

s^ 
■"  c 
^A 
s  p. 
ffl  >^ 

<t  © 

32 

:rg 

IE  S 

.a  c 

a" 

, 
o 

'H    la 

a_© 

'3 

re  n 

o 
m  g 

"Ss 

—  c3 

CC-l- 

1° 

o 

"So 

>   CS 

sri 

Is 

-2  CO 

1l 

®=s 

:e  (D 
-C  g 

©3 

cS  - 

?'  © 

o 

(0 

% . 
•s-i 

> 

Company  totals 
(directandin- 

direct). 

Regimental 
totals. 

Regiment. 

to  D 

D  o 

;:  S 

■"  Cl 

o 

atl 
... 

il 

Si's  2 

tJ3>cS 
<1 

CO  © 

ts. 
Is 

CO  3 

< 

Si  ^ 

©  o 
ji  © 

:i 

o 

-     ©  CO 

III 

S    ©.t.5 

©  0 

+3  a; 

fl  s 

11 

S  B  tc 

'O    ©    M 

£2 

bl^  cS 
?       © 

Si's  2 

<5 

55 

cS/2 
^5 

CD   O 
&° 

©?5 
111 

o  ©is 
!>.0  cS 
< 

3.5th  Michigan. - 

A 
L 

45 
29 

14         U9 

10.6 
11.2 

15 

7 

143 

85 

9.5 
12.1 

29 
11 

292 
130 

10.0 
11.8 

4 

45 

Total 

74 

40 

422 

10.5 

A 
C 
K 

20-3d    New  York 

61 

45 

48 

15 
10 
11 

145 
l;il 
124 

9.6 
12.1 
11.2 

15 

8 
12 

145 

89 

119 

9.6 

11.1 

9.9 

30 
18 
23 

.290 
210 
243 

9.6 
11.6 
10.5 

Total 

154 

71 

743 

10.4 

— ■ 

228 

54 

584 

10.8 

57 

581 

10.1 

111 

1,165 

10.4 

Table  shoioing  average  interval  between  diarrheal  and  typhoidal  attacks  in  same 
individual  {as  deduced  from  lists  of  diarrhea  pirecedlng  typhoid),  in  eight  regi- 
Tnenis  of  the  Second  Army  Corps,  at  Camp  Meade,  Pa. 


Regiment. 

Number 
of  diar- 
rheas 
preced- 
ing 
typhoid. 

Aggregate 
days  of 
interval 
between 
attacks. 

Average 
days  of 
interval 
between 
attacks. 

4 

2 

11 

26 

4 

1 

6 

12 

41 
21 
122 

306 
40 
12 
52 

153 

10.2 

10.5 

11.0 

11.7 

201st  New  York            .                               

10.0 

202d  New  York         - 

12.0 

203d   New  York _ 

8.6 

10th  Ohio       

12.7 

66 

747 

11.3 

123 

Table  shoifinq  for  the  regiments  of  the  Second  Army  Corps  assembled  at  Camp 
Meade,  Pa.,  the  viortalify  and  inorbidity  from  typhoid  fever. 


Mean 
strength. 

Cases  of  typhoid  fever. 

Deaths 

Regiment. 

Certain. 

Certain 

and 
probable. 

from          „^ea^'^f. 

FIRST   DIVISION. 

1,251 
1,150 
1,228 
1,214 
1,125 
1,280 

51 
269 
141 
132 
110 
415 

96 

385 
317 
168 
195 

475 

7 
31 
22 
13 
10 
18 

13 

35th  Michigan       . 

25 

10th  Ohio 

22 

3d    Connecticut  _ 

14 

202d    New  York    

11 

18 

Total 

7,248 

1,118 

1,636 

91 

102 

SECOND  DIVISION. 

4th  New  York             

1,225 
1,047 
1,165 
1,275 
1.076 
926 

6 
371 

13 

0                    n 

203d    New  York                             .     . 

16 
15 
8 

19 
6 

18 

112  i              219 
43  1                66 
119  1              195 

30  j                58 

17 

3 

201st  New  York   .                        

21 

Total 

6,714 

681 

1,054 

59 

66 

13,962 

1,799 

2,690 

150 

168 

2d   Pennsylvania 

1,070 

3 

9 

2 

2 

Regiment. 


Deaths  from  ty- 
phoid fever  in 
100  cases — 


Certain 
typhoid. 


Certain 
and 

proba- 
ble. 


Percent- 
age of 
deaths 
from  ty- 
phoid to 
deaths 
from  all 
diseases. 


Morbidity  of  ty- 
phoid fever 
per  1,000  mean 
strength— 


For  cer- 
tain 
cases  of 
typhoid. 


Deaths 
from  ty- 

'    phoid 

For  cer- 1  fever  in 
tain  and  i  1,000  per 
proba-   I    mean 
ble  cases  strength, 
of  ty- 
phoid. 


FIRST  DIVISION. 

1st  Maryland.. 

:i5th  Michigan 

10th  Ohio 

3:1    Connecticut- 

202d   New  York 

1.5th  Minnesota 

Total 

SECOND   DIVISION 

4th  New  York 

203d    New  York 

2d    West  Virginia  .  

5th  Massachusetts 

201st  New  York 

1st  Delaware 

Total 

Total  Second  Corps.. 
2d   Pennsylvania 


13.72 

7.80 
15.60 
9.84 
9.09 
4.33 


5.45 
6.94 
7.73 
5.12 

3.78 


58.33 
84.00 

100.00 
92.85 
90.90 

100. 00 


40.76 
233.91 
114. 82 
108.  73 

97.77 
324.21 


76.73 
334.78 
258.24 
138.38 

173.  as 

371.09 


5.59 
18.26 
17.93 
10.70 

8.88 
14.06 


8.13 


5.56 


89.21 


154.24 


225.71 


0 

4.31 

13.39 

6.97 

15. 96 

20.00 


0 

3.18 
6.84 
4.57 
9.74 
10.34 


0 
88.88 
88.23 
100.00 
90.50 
85. 71 


4.89 
354.30 
96. 13 
33.72 
110.59 
32.39 


10.61 

480.42 
187. 97 

51. 75 
181.22 

62.63 


5.59 


89.39 


101.42 


156. 98 


8.33 


5.57 


89.28 


128.84 


192.67 


66.66 


22.22 


100.00 


8.41 


12.55 


0 
15.28 
12.87 

2.34 
17.65 

6.46 


8.78 
~r86 


124 

CHAPTER  IX. 

TYPHOID   FEVER   IN  THE   FOTJHTH   ARMY  CORPS. 

Commands. — First  Ohio,  Third  Pennsylvania,  One  hundred 
and  fifty-seventh  Indiana,  Thirty-second  Michigan,  Second 
Georgia,  Fifth  Ohio,  Fifth  United  States  Cavalry. 

It  is  impossible  to  follow,  in  the  study  of  typhoid  fever  in  this 
corps,  the  same  methods  adopted  in  our  studies  of  the  First  and 
Third  Army  Corps.  In  the  first  place,  the  regiments  of  the  Fourth 
Army  Corps  were  frequentlj^  changed,  some  going  to  other  organiza- 
tions and  others  coming  from  other  organizations.  The  Fourth  Army 
Corps  assembled  near  Mobile,  Ala.,  at  the  place  which  we  have  desig- 
nated as  Camp  Coppinger.  While  at  this  place  six  regiments  (the 
First  and  Second  Alabama,  the  First  and  Second  Louisiana,  and  the 
First  and  Second  Texas)  were  detached  from  this  corps  and  sent  to 
Miami,  Fla. ,  where  these  regiments  constituted  the  First  Division  of 
the  Seventh  Army  Corps.  A  study  of  the  medical  history  of  these 
regiments  will  be  found  in  the  history  of  the  Seventh  Corps.  The 
regiments  left  at  Mobile  after  the  detachment  of  the  six  regiments 
mentioned  above  subsequently  were  moved  to  Tampa,  Fla. ,  and  its 
vicinitj^  Here  the  Fourth  Corps  was  recruited  by  regiments  sent 
from  Chickamauga  and  others  sent  from  State  encampments.  The 
regiments  sent  from  Chickamauga  to  the  Fourth  Army  Corps  at 
Tampa  were  the  Second  Xew  York  Volunteer  Infantry,  the  Sixty- 
ninth  New  York  Volunteer  Infantry,  the  Fifth  Maryland  Volunteer 
Infantry,  and  the  First  Ohio  Volunteer  Cavalry.  The  historj'  of 
typhoid  fever  in  these  regiments  has  ali'eady  been  discussed  in  con- 
nection with  the  First  and  Third  Army  Corps.  Other  regiments — the 
Third  Pennsylvania  Volunteer  Infantry,  the  One  hundred  and  fifty- 
seventh  Indiana  Volunteer  Infantry,  and  the  First  Ohio  Volunteer 
Infantry — stopped  for  a  few  daj^s  at  Chickamauga  Park  on  their  way 
from  State  encampments  to  Tampa.  Other  regiments,  such  as  the 
Fifth  Ohio  Volunteer  Infantry,  the  Third  Pennsylvania  Volunteer 
Infantry,  the  Second  Georgia  Volunteer  Infantry,  the  First  Florida 
A'olunteer  Infantry,  and  the  Thirty-second  Michigan  Volunteer  In- 
fantry, went  directly  from  theii-  State  encampments  to  join  the  Fourth 
Army  Corps  at  Tampa.  It  will  be  seen  from  the  above  that  the  his- 
tories of  ten  regiments  (First  and  Second  Alabama,  First  and  Second 
Louisiana,  First  and  Second  Texas,  Fifth  Maryland  Volunteer  Infan- 
try, Second  New  York  Volunteer  Infantry,  Sixtj^-ninth  New  York 
Volunteer  Infantry,  and  the  First  Ohio  Volunteer  Cavalry),  at  one 
time  attached  to  the  Fourth  Army  Corps,  have  already  been  given  in 
connection  with  other  organizations. 

In  the  second  place,  the  brigades  of  the  Fourth  Army  Corps  at 
Tampa  were  quite  widely  separated,  and  the  conditions  of  the  various 


125 

camps  differed  somewhat.  One  brigade  (at  that  time  tlie  Third  Bri- 
gade of  the  Second  Division  of  the  Fourth  Army  Corps),  consisting  of 
the  First  Ohio  Volunteer  Infantry,  the  One  hundred  and  fifty-seventh 
Indiana  Volunteer  Infantry,  and  the  Thii'd  Pennsylvania  Volunteer 
Infantry,  was  encamped  near  Port  Tampa  City.  The  Second  Brigade 
of  the  Second  Division  (consisting  earlj^  in  June,  1898,  of  the  First 
District  of  Columbia  Volunteer  Infantry,  Second  New  York  Volunteer 
Infantry,  and  Fifth  Maryland  Volunteer  Infantry)  was  encamped  for 
a  while  in  the  vicinity  of  old  Fort  Brooke.  Later  in  June  the  First 
District  of  Columbia  Volunteer  Infantry  went  to  Cuba  and  became  at- 
tached to  the  Fifth  Army  Corps.  The  Fifth  Ohio  Volunteer  Infantry, 
the  Third  Ohio  Volunteer  Infantry,  the  Thirty-second  Michigan  Vol- 
unteer Infantry,  the  First  Florida  Volunteer  Infantry,  and  the  Second 
Georgia  Volunteer  Infantry  were  encamped  in  De  Soto  Park  and 
along  Palmetto  Beach,  immediately  southeast  of  Tampa.  The  Fifth 
U.  S.  Cavalry,  the  Second  IT.  S.  Cavalry,  and  the  First  U.  S.  Volunteer 
Cavalry  (until  its  departure  for  Cuba)  were  located  immediately  to 
the  west  of  Tampa  Bay  Hotel.  The  Eleventh  U.  S.  Infantry  and 
the  Nineteenth  II.  S.  Infantry  were  located  to  the  north  of  the  city. 
There  was  also  one  brigade  at  Lakeland,  Fla.,  some  30  miles  distant 
from  Tampa.  In  Julj^  the  Nineteenth  U.  S.  Infantry  and  the  Eleventh 
U.  S.  Infantry  were  sent  to  Porto  Rico. 

During  the  latter  part  of  July  a  part  of  the  Fourth  Army  Corps  was 
moved  to  Fernandina,  Fla.,  and  later  (during  the  latter  part  of 
August)  the  whole  of  this  corps  was  transferred  to  Huntsville,  Ala. 

We  will  attempt  to  give  the  histories  of  only  a  few  of  the  regiments 
of  this  corps.  These  will  be  sufficient  to  make  us  acquainted  with  the 
sanitary  conditions  of  the  camps  occupied  by  this  command.  While 
we  do  not  think  that  we  have  overestimated  the  number  of  cases  of 
typhoid  fever  in  these  regiments,  we  desire  to  state  that  we  can  not 
be  so  jjositive  on  this  point  as  we  were  concerning  the  regiments  at 
Chickamauga,  because,  for  the  reasons  to  be  stated  later,  we  are  con- 
vinced that  malaria  was  much  more  prevalent  among  troops  encamped 
about  Tampa  than  it  was  in  the  First  and  Third  Army  Corps. 

H5  *  *  *  H<  H=  * 

The  conditions  of  the  various  camps  occupied  by  this  corps  have 
been  given  in  connection  with  the  different  regiments.  It  will  be  seen 
that  while  water  contamination  can  not  be  excluded  in  the  camps 
about  Tampa,  typhoid  fever  must  have  been  disseminated  by  other 
agencies  in  the  encampments  at  Fernandina  and  Huntsville.  Typhoid 
infection  appeared  among  the  regular  troops  at  Tampa  before  any 
of  the  volunteer  regiments  reached  that  place.  The  Second  and 
Thirteenth  TJ.  S.  Infantry  furnished  recognized  cases  of  tj^phoid 
fever  soon  after  reaching  Tampa  in  May.     The  last-mentioned  organi- 


126 

zation  Avas  stationed  at  Fort  Niagara  and  Fort  Porter,  N.  Y.,  when 
war  was  proclaimed,  and  it  reached  Tampa  with  one  man  sick  with 
typhoid  fever.  So  far  as  we  have  been  able  to  ascertain  this  was  the 
first  case  of  this  disease  among  the  troops  assembled  at  Tampa  and  in 
its  vicinity  in  1898.  On  June  7,  1898,  the  Fourth  Corps  reserve  hos- 
pital was  opened,  and  on  this  date  it  received  9  cases  of  recognized 
tyjjhoid  fever.  Three  of  these  were  from  the  Thirteenth  Infantry  and 
one  each  from  the  Second,  Fourth,  Sixth,  Sixteenth,  Twenty-second, 
and  Twenty-fourth  Infantry,  and  before  the  last  of  June  the  follow- 
ing additional  regular  regiments  sent  cases  of  recognized  typhoid  fever 
to  this  hospital:  Second  and  Fifth  Cavalry  and  Third  and  Eleventh 
Infantry.  It  will  thus  be  seen  that  many  of  the  regular  regiments 
entered  upon  the  campaign  already  infected  with  typhoid  fever. 
There  is,  therefore,  no  difficulty  in  accounting  for  the  introduction  of 
t\'phoid  fever  into  the  camps  about  Tampa,  since  many  of  both  regu- 
lar and  volunteer  regiments  reached  that  place  bringing  with  them 
the  infection. 

The  following  talkie  shows  at  least  approximate  facts  concerning 
typhoid  fever  in  the  regiments  the  histories  of  which  we  have  just 
U'iven : 


Regiment. 


S-^ 


«  te  > 
Oh  ^ 


"^^  SB 

o  a  . 

(S  c3  O 

©"O  p. 


""  aotB 

O  fl  0) 

«,°§ 
®  go 

-t^  to  2 

(D4^  bo 
O  tS  O 

P4 


l^,t  Ohio i  1.085  221  !  20.36 

l.jTth  Indiana I  1,080  219!  20.27 

3d    Pennsylvania I  783  92?  11.741 

32d    Michigan I  1.2;B9  253  20.41 

2d   Georgia !  1,100  184  16.72 

othOhio - 1,320  310!  23.48 

5th  U.  S.  Cavalrv 900^  219  24.33 


27 
2 
23 
34 
47 
88 
219 


4.07 
6.39 
10.86  i 
7.  .50  I 
7.06 
6.45  • 
6.39  1 


33.33 
700. 00 
43.47 
55.88 
27.65 
22.72 
6.39 


Total  strength  for  these  regiments  in  July 7, 507 

Total  number  of  probable  case.s  of  typhoid  fever  in  these  seven  regiments. .  1, 498 

Percentage  of  probable  cases  of  typhoid  fever  in  these  regiments 19. 95 

Number  of  recognized  cases  of  typhoid  fever  in  these  regiments 440 

Number  of  deaths  due  to  typhoid  fever  in  these  regiments 99 

Percentage  of  deaths  among  probable  cases  of  typhoid  fever  ... 6. 60 

Percentage  of  deaths  among  recognized  cases  of  typhoid  fever 22. 50 

It  will  be  seen  from  these  figures  that  the  percentage  of  deaths 
among  probable  cases  of  typhoid  fever  in  these  regiments  is  slightly 
lower  than  it  was  among  the  troops  at  Chickamauga,  while  the  per- 
centage of  deaths  among  recognized  cases  is  considerably  higher. 

We  are  quite  confident  that  the  number  of  cases  of  probable  typhoid 
fever  in  the  Third  Pennsylvania  Volunteer  Infantry  as  given  in  the 
above  table  is  much  too  low.     On  the  other  hand,  it  is  possible  that 


127 

we  have  overestimated  the  number  of  probable  cases  of  typhoid  fever 
in  the  First  Ohio  Volunteer  Infantry. 

We  have  elsewhere  stated  that  we  have  reason  for  believing  that 
malaria  was  more  frequent  among  troops  stationed  at  Tampa  than  it 
was  among  those  encamped  at  Chickamauga.  The  board  did  not  have 
opportunity  to  have  blood  examinations  made  among  the  troops  of  the 
Fourth  Army  Corps,  and  our  reason  for  belie^dng  that  malaria  was 
more  prevalent  among  those  troops  is  founded  upon  information  fur- 
nished us  b}'^  Dr.  G.  W.  Moorehouse,  resident  physician  of  the  Lake- 
side Hospital,  at  Cleveland,  Ohio.  The  Fifth  Ohio  Volunteer  Infantry 
was  from  Cleveland,  and  when  disbanded  its  sick  were  sent  in  part 
to  this  hospital.  Here  blood  examinations  were  made  by  Dr.  E.  P. 
Carter.  The  malarial  organism  was  found  in  23  individuals  from 
this  regiment.  In  5  of  these  cases  malaria  and  typhoid  fever  were 
coincident. 

We  append  a  table  showing  for  the  regiments  of  the  Fourth  Armj' 
Corps  the  mortality  and  morbidity  from  typhoid  fever. 

Table  shoicing  for  the  regiments  of  the  Fourth  Army  Corps  {assembled  at  Mobile, 
Cliickamauga,  and  Tam}oa)  the  mortality  and  morbidity  from,  typhoid  fever. 


Regiment. 


Mean 
strength. 


Cases  of  typhoid 
fever. 


I    Certain 
Certain,    i        and 

probable. 


Deaths 

from 

typhoid 

fever. 


Deaths 
from  all 
diseases. 


1st  Ohio , 

1.57th  Indiana 

od    Pennsylvania 
32d    Michigan  .... 

2d    Georgia. 

.5th  Ohio.. 

.5th  U.  S.  Cavalry 

Total 


Regiment. 


1,085 
1,080 

783 
1,239 
1,100 
1.320 

900 


27 
2 

23 
34 

47 

88 

219 


221 
219 
92 
253 
184 
310 
219 


,507 


440 


10 
18 
13 
20 
14 
23 
16 


112 


Deaths  from  ty- 
phoid fever  in    Percent- 
100  cases  of—  age  of 

:, 1  deaths 

from 


Certain 


Certain    tyP^'Ji"! 


and 


to  deaths 
from  all 


Morbidity  of  ty- 
phoid'fever 
in  1.01  0  mean 
strength. 


For 
certain 


For  cer 
!  tain  and 


Deaths 

from 

typhoid 

fever  in 

1.1 100  of 


'^'^^-  prS^:^.:^^-^    ca^esof   P/asefof'^t--^"^- 
diseases,     ypj^^j^    typhoid 


1st  Ohio 

L57th  Indiana 

3d    Pennsylvania  . 

.32d    .Michigan 

2d    Georgia 

5th  Ohio 

5th  U.S. Cavalry.. 


Total 


33. 


4.07 
6.  .39 
10.86 
7.50 
7.06 
6.45 
6.39 

6.60 


99.00 
77.77 
8-3.33 
95.00 
92.87 
90.90 
87.50 

88.39 


24.88 
1.85 
29.37 
27.44 
42.72 
66.66 
24.3.33 

58.61 


203.68 
203.77 
117.  49 
204. 19 
167. 27 
234.84 

243.  as 

199.54 


8.25 
13.96 
12.77 
15.33 
11.81 
1.5.15 
15.  .55 

13.17 


128 

CHAPTER  X. 

TYPHOID  FEVER  IN  OTHER  ORGANIZATIONS  AT  CHICKAMAUGA. 

Organizations. — Third  U.  S.  Volunteer  Cavalry,  Cavalry  Brigade, 
First  Corps;  First  Illinois  Volunteer  Cavalry;  First  Ohio  Volunteer 
Cavahy;  Light  Artillery  Brigade,  First  Coi'ps;  Sixth  U.  S.  Volunteer 
Infantry;  Eighth  U.  S.  Volunteer  Infantry;  hospital  corps  men, 
First  and  Third  Army  Corps;  female  nurses  at  Chickamauga. 

TYPHOID     FEVER     AMONG     HOSPITAL    CORPS    MEN    IN    THE    FIRST   AND 

THIRD  ARMY   CORPS. 

We  have  been  unable  to  obtain  a  statement  of  the  strength  of  the 
hospital  corps  connected  with  the  First  and  Third  Army  Corps.  We 
find  in  the  records  of  the  various  hospitals  connected  with  the  First 
and  Third  Armj^  Corps  200  cases  of  recognized  typhoid  fever  among 
the  hospital  corps  men.  At  the  time  that  we  inspected  the  troops  at 
Chickamauga  Capt.  H.  B.  Stotter  was  in  command  of  the  hospital 
corps.  He  stated  that  he  had  under  his  charge  110  men  all  told. 
The  duties  of  these  men  consisted  in  acting  as  orderlies  at  Sternberg 
hospital  and  in  policing  the  grounds.  Captain  Stotter  had  at  that 
time  been  at  Chickamauga  for  five  weeks,  but  had  had  charge  of  the 
hosijital  corps  for  only  three  weeks.  In  fact,  he  was  placed  in  charge 
a  short  time  after  the  opening  of  Sternberg  hospital.  At  the  time  of 
his  taking  charge  of  this  cor]3s  all  the  men  in  it  were  on  duty.  At 
the  time  when  he  gave  his  testimony  to  us  36  were  on  the  sick  report; 
16  of  these  were  in  the  hospital.  The  prevailing  diseases  among  the 
20  in  quarters  were  diarrhea  and  gastritis.  Captain  Stotter  attributed 
the  gastritis  to  the  fact  that  these  men  drank  too  freely  of  infected 
milk.  When  we  visited  Sternberg  hospital  we  found  the  hospital 
corps  men  drinking  Chickamauga  Creek  water  from  the  hydrants, 
although  this  water  had  been  condemned.  Captain  Stotter  attributed 
the  diarrhea  among  his  men  to  the  use  of  this  water.  He  reported 
that  his  men  were  fairly  intelligent,  amenable  to  discipline,  and  but 
little  given  to  intoxication. 

i^  ■if  9^  :^  ^  ^  ^ 

It  would  be  interesting  if  we  could  ascertain  the  total  number  of 
cases  of  typhoid  fever  among  the  hospital  corps  men,  on  account 
of  the  close  contact  these  men  had  with  typhoid  patients.  It  was 
customary  during  a  part  of  the  time  at  Chickamauga,  as  it  was  at 
other  national  encamiaments,  to  detail  men  from  the  line  to  serve  as 
orderlies  in  the  hospitals.  In  some  places  these  details  were  made 
daily ;  in  others  a  detail  was  made  for  a  week.  At  the  expiration  of 
the  time  for  which  the  detail  was  made  the  men  were  returned  to 
their  respective  regiments  and  other  men  for  like  purposes  detailed  at 
the  hospital.     This  method  of  securing  orderlies  to  care  for  patients 


129 

with  typhoid  fever  or  other  infectious  disease  is  to  be  condemned 
most  emphatically.  Undoubtedly  this  was  one  of  the  means  by  which 
typhoid  fever  was  spread  through  the  different  organizations.  Men 
wholly  ignorant  of  methods  of  disinfection  were  assigned  to  the  task 
of  caring  for  patients  and  disinfecting  stools.  Many  of  these  men 
undoubtedly  infected  themselves  and  went  back  to  their  regiments 
without  even  disinfecting  their  hands.  At  one  hospital  we  found 
that  the  orderlies  went  to  their  respective  messes  in  the  different 
regiments  "svithout  washing  their  hands. 


CHAPTER  XI. 

TYPHOID   FEVER   IN  THE    FIRST  AND  SECOND  DIVISIONS, 
SEVENTH  ARMY  CORPS. 

GENERAL   REMARKS  ON  THE  FIRST  DIVISION   CAMP  AT   MIAMI,  FLA. 

The  selection  of  Miami  as  a  camp  for  troops  gave  occasion  for  much 
criticism,  and  it  was  the  general  belief  of  the  medical  officers  of  the 
Seventh  Corps  that  the  water  supplied  the  troops  at  this  place  was 
contaminated  and  was  the  cause  of  the  large  amount  of  sickness  in  the 
division  encamped  there. 

July  13  Lieutenant-Colonel  Maus,  chief  medical  officer  of  the  Sev- 
enth Corps,  went  to  Miami  for  the  purpose  of  inspecting  the  camp. 
On  his  return  to  corps  headquarters  at  Jacksonville  he  made  a  report 
to  the  Surgeon-General,  from  which  the  following  quotations  are 
taken : 

The  division  at  Miami  consists  of  six  regiments — First  and  Second  Alabama, 
First  and  Second  Texas,  and  First  and  Second  Louisiana — and  contains  about 
7,500  men.  I  was  very  much  surprised  to  find  such  an  unusually  large  percentage 
of  sickness  in  this  command.  On  the  day  of  my  arrival  over  600  were  on  the  sick 
report,  besides  almost  that  number  suffering  from  various  complaints  but  not  on 
sick  report.  Many  of  this  supplementary  list  were  having  dysentery  and  diar- 
rhea, witn  from  six  to  ten  evacuations  daily.  The  principal  troubles  consist  of 
diarrhea  and  dysentery  and  malarial  fevers,  and  there  appears  to  be  a  universal 
opinion  among  of&cers  and  men  that  these  diseases  are  due  to  the  water  supply. 
I  made  a  careful  inspection  of  the  camp  and  found  it  otherwise  in  good  sanitary 
condition.  The  regiments  are  located  in  piney  groves  adjacent  to  the  city  and 
on  a  coraline  formation.  The  ground  is  not  pleasant  for  camping  purposes,  because 
it  is  almost  impossible  to  laroperly  pitch  the  tents,  and  is  very  disagreeable  for 
walking  on,  as  it  cuts  the  shoes  and  is  disagreeable  for  the  feet  when  they  are 
bare.  The  night  soil  is  disposed  of  by  being  deposited  in  troughs  partly  filled 
with  water.  These  troughs  are  connected  with  the  sewers  and  are  emptied  and 
flushed  frequently,  but  in  some  regiments  the  night  soil  is  deposited  in  tubs, 
which  are  carted  away  and  emptied  into  the  sea.  Pits  are  used  at  some  regimental 
head(iuarters.     The  contents  of  these  are  covered  from  day  to  day. 

The  water  supply  is  from  two  sources.  The  city  of  Miami  is  supplied  with 
7273 9 


130 

water  taken  from  an  open  lake  in  the  Everglades,  about  4  miles  distant.  The 
water  is  piped  to  the  city  and  distributed  through  the  camp  at  convenient  places. 
The  other  source  is  from  d-riven  wells  which  penetrate  the  coraline  formation  for 
a  distance  of  from  18  to  21  feet.  The  water  comes  from  the  wells  turbid  and  con- 
tains a  large  amount  of  suspended  matter  which  deposits  quickly  on  standing.  It 
has  a  disagreeable  taste  and  odor.  I  regard  this  water  as  unfit  for  use  and  believe 
it  to  be  surface  drainage.  Many  of  the  regimental  ofScers  have  become  so 
thoroughly  convinced  that  this  water  is  the  chief  cause  of  the  prevailing  illness 
that  they  have  forbidden  its  use  and  have  caused  the  handles  to  be  removed  from 
the  pumps.  The  water  from  the  Everglades  is  also  turbid.  It  has  a  marshy  taste 
and  a  decided  odor.  In  my  opinion,  this  water  is  probably  productive  of  the 
malarial  troubles.  Thus,  the  soldier  stands,  as  it  were,  between  two  dangers — 
the  well  water  probably  infected  with  typhoid,  and  the  Everglade  water,  probably 
infected  with  the  malarial  poison.  The  Everglade  water  is  much  warmer,  and 
consequently  the  soldier  prefers  that  from  the  wells.  The  lake  in  the  Everglades 
collects  the  drainage  of  an  extended  territory  covered  with  tropical  vegetation 
and  is  filled  with  tall  grass. 

The  division  hospital  is  located  on  a  vacant  lot  in  the  center  of  the  town.  The 
tents  are  crowded.  The  ground  is  low  and  covered  with  brush  and  other 
vegetation.  The  lot  has  been  partially  cleared  and  some  of  the  holes  in  it  have 
been  filled.  One  of  these  holes  is  about  30  feet  in  diameter  and  6  feet  deep.  It 
seems  to  have  been  used  as  a  deposit  for  rubbish,  I  expressed  disapproval  of  this 
site,  and  had  a  board  appointed  to  select  a  suitable  one  outside  of  the  city. 

On  the  day  of  my  arrival  the  hospital  contained  269  cases,  many  of  which  were 
mumps,  measles,  intestinal  troubles,  and  continued  fevers.  Only  8  of  these  con- 
tinued fevers  were  diagnosticated  as  typhoid,  though  thej^  were  continued  and 
presented  many  of  the  symptoms  of  that  disease,  such  as  hebetude,  iliac  tender- 
ness, gurgling,  and,  in  some  instances,  rose-colored  spots.  These  are  unquestion- 
ably naild  cases  of  typhoid  fever.  I  believe  that  the  Widal  test  should  be  made 
in  all  doubtful  cases,  and  for  this  purpose  I  suggest  that  the  hospital  be  supplied 
with,  pure  cultures  of  the  typhoid  bacillus. 

In  a  letter  to  the  Adjutant-General,  Colonel  Mans  makes  the  fol- 
lowing additional  statement  concerning  the  water: 

Major  Archinard,  who  has  taken  an  active  interest  in  this  matter,  had  forwarded 
before  my  arrival  samples  of  water  for  analysis  to  Tulane  University.  The  fol- 
lowing telegram  has  been  received  from  him: 

"The  chemist.  Dr.  Metz,  says  well  water  is  contaminated  with  sewage.  It 
contains  large  amounts  of  free  and  albuminoid  ammonia,  nitrates,  and  nitrites. 
Everglade  water  contains  much  vegetable  matter.  The  bacteriologist,  Dr.  P.  E. 
Archinard,  states  that  a  cursory  examination  shows  both  waters  unfit  for  drinking 
purposes. " 

Colonel  Wood,  chief  commissary  of  the  Seventh  Corps,  under  date 
of  July  21,  wrote  concerning  the  water  as  follows: 

To  say  nothing  of  the  extremely  high  temperature  of  this  water  (the  Ever- 
glade), owing  to  the  direct  action  of  the  sun  on  the  pipes,  the  water  is  about  the 
color  of  that  of  the  Missouri  River  and  has  a  taste  of  vegetable  matter  that  ren- 
ders it  unpleasant.  To  offset  this,  the  troops  have  driven  wells  close  to  the  com- 
pany kitchens,  and  this  water,  while  cooler,  is  daily  contaminated  by  the  slop  and 
dishwater  thrown  on  the  ground  to  be  pumped  up  again.  To  use  either  water 
seems  to  be  the  choice  of  two  evils— malaria  or  typhoid  fever — and  I  would  ear- 
nestly recommend  that  the  troops  of  the  First  Division  be  moved  away  from 
Miami,  where  the  sick  list  is  already  amazingly  large  and  daily  increasing. 


131 

Colonel  Guild,  inspector-general  of  the  Seventh  Corps,  writes  of 
this  water  as  follows,  nnder  date  of  July  19: 

The  main  water  supply  comes  from  the  swamp  known  as  the  Everglades.  Sam- 
ples tried  by  me  had  an  offensive  odor.  The  men  universally  believe  it  to  be 
infected.  This  water  is  distributed  through  pipes  lying  on  the  surface  of  the 
ground,  and  consequently  it  is  hot  and  unpalatable.  Thus  the  men  are  encour- 
aged to  drink  the  cooler  but  infected  water  of  the  driven  wells. 

A  medical  board  was  convened  by  Colonel  Maus  for  the  purpose  of 
ascertaining  the  cause  of  the  great  sickness  in  this  division.  This 
board  consisted  of  Major  Peoples,  of  the  Second  Texas;  Major  Pugh, 
of  the  Second  Alabama,  and  Captain  Blanchard,  of  the  First  Louisiana. 
These  gentlemen  agreed  that  the  water  was  infected.  A  second  board, 
consisting  of  Major  Archinard,  of  the  Second  Louisiana;  Major  Vilas, 
of  the  First  Texas,  and  Lieutenant  Jackson,  of  the  First  Alabama, 
was  requested  to  determine  the  nature  of  the  continued  fevers  preva- 
lent in  this  camp.  After  making  one  post-mortem  examination  and 
having  a  large  number  of  samples  of  blood  submitted  to  the  "Widal 
test,  they  concluded,  Julj^  20,  that  there  were  50  instead  of  only  8 
cases  of  typhoid  fever  in  the  division  hospital. 

It  seems  to  have  been  unquestionably  demonstrated  that  the  water 
first  supplied  through  the  pipes  as  Everglade  water  was  in  reality 
pumped  from  a  large  shallow  well,  the  situation  of  which  rendered  its 
contents  quite  as  likely  to  be  infected  as  was  the  water  from  the  regi- 
mental wells.  After  the  disco verj^  of  this  deceit  the  Everglade  water 
was  furnished. 

THE   FIEST  DIVISION  CAMP  AT  JACKSONVILLE. 

This  camp  site,  which  was  occupied  on  August  5,  was  located  on 
ground  bordering  on  the  west  bank  of  the  St.  Johns  River,  near  the 
suburb  of  Fairfield.  The  general  elevation  of  the  site  was  about  15 
feet  above  the  river  and  admitted  of  fair,  natural  drainage,  the  ground 
sloping  slightly  from  the  river  toward  the  shell  roads.  The  soil  con- 
sisted of  sand  which  rapidly  absorbed  the  rainfall.  Shade  trees  were 
plentifully  interspersed  throughout  the  camp. 

The  water  supply  of  this  division  was  piped  to  the  company  streets 
from  the  deep  artesian  well  of  the  Country  Club  at  Fairfield. 

For  about  two  weeks  after  the  arrival  of  the  division  from  Miami, 
Fla.,  pits  were  dug  along  the  shell  road  in  rear  of  the  regimental 
camp  sites  for  the  reception  of  excreta  and  garbage.  At  the  date  of 
our  inspection,  August  28,  1898,  a  sj^stem  of  water  carriage  for  excreta 
had  been  already  instituted  for  the  regiments  of  this  division.  Boxes 
lined  with  zinc,  having  a  capacity  of  20  feet  by  18  bj?^  20  inches  were 
provided.  These  were  supplied  with  a  constant  stream  of  water,  and 
at  intervals  of  about  one  hour  were  emptied  into  the  sewer  and  thor- 
oughly flushed  out.  The  sewer  pipes  discharged  into  the  St.  Johns 
River.     Provision  was  made  against  overflow  of  these  trousrhs. 


132 

At  tlie  time  of  our  inspection,  therefore,  there  was  nothing*  objec- 
tionable, either  in  the  matter  of  the  water  supply  or  in  the  disposal  of 
the  excreta  of  these  regiments. 

FIRST  DIVISION   OP  THE   SEVENTH  ARMY   CORPS. 

At  the  time  of  our  inspection,  August  28  to  September  5,  1898,  this 
division  consisted  of  the  following  regiments :  First  Alabama  Infantry, 
Second  Alabama  Infantry,  First  Louisiana  Infantry,  Second  Louisiana 
Infantry,  First  Texas  Infantry,  Second  Texas  Infantry,  Fourth  U.  S. 
Volunteer  Infantry,  and  First  Ohio  Infantry. 

The  two  last-mentioned  regiments,  however,  had  been  with  this 
division  only  a  few  days,  and  it  will  be  more  satisfactory  to  consider 
the  division  as  consisting  of  only  six  regiments,  two  from  Alabama, 
two  from  Louisiana,  and  two  from  Texas. 

Table  showing,  for  the  regiments  of  the  First  Division  of  the  Seventh  Army  Corps 
assembled  at  Jacksonville,  Fla.,  the  mortality  and  morbidity  from  typhoid 
fever. 


Regiments. 

Mean 
strength. 

Certain 

and 

probable 

cases  of 

t  J  phoid 

fever. 

Deaths 

from 

typhoid 

fever. 

Deaths 
from 
all  dis- 
eases. 

Deaths 

from 

typhoid 

fever  in 

100  cases. 

Percent- 
age of 
deaths 
from 
typhoid 
to  deaths 
from  all 
diseases. 

Morbid- 
ity of 
typhoid 
fever  in 
1,000 
mean 
strength. 

Deaths 
from 

typhoid 

fever  in 

1,000 

mean 

strength. 

1,178 
1,079 
1,224 
1,102 
1,105 
1,164 

158 
159 
269 
177 
111 
156 

10 
8 

11 
8 
8 
8 

16 
16 
16 
15 
13 
15 

6.32 
.5.03 
4.08 
4.51 
7.20 
5.13 

63.50 
50.00 
68.75 
53.33 
69.23 
53.33 

134.13 
147.85 
219. 77 
160. 61 
100. 45 
134. 02 

8.48 

7.41 

1st  Louisiana 

2d  Louisiana 

1st  Texas  

8.98 
7.25 

7.33 

3d  Texas 

6.87 

Total... 

6,852 

1,030 

53 

91 

5.14 

58.24 

■  1-50.32 

r.73 

THE  SECOND   DIVISION   CAMP  AT  JACKSONVILLE. 

Commands. — Second  New  Jersey  Infantry,  Second  Illinois  In- 
fantry, First  North  Carolina  Infantry,  Fiftieth  Iowa  Infantry, 
First  Wisconsin  Infantry.  Second  Virginia  Infantry,  Fourth 
Virginia  Infantry,  Forty-ninth  Iowa  Infantry,  Ninth  Illinois 
Infantry. 

This  site  was  within  the  city  limits,  being  placed  on  a  rather  level 
strip  of  land  situated  between  the  extension  of  Main  street  and  the 
Jacksonville  and  Fernandina  Railroad.  The  sketch  map  which  fol- 
lows will  show  the  location  of  the  several  regiments  in  their  first  en- 
campment at  Camp  Cuba  Libre.  Later,  when  typhoid  fever  became 
quite  prevalent  in  certain  regiments,  the  Mnth  Illinois,  Fiftieth  Iowa, 
and  First  Wisconsin  were  moved  to  a  somewhat  more  elevated  site 
about  1  mile  west  of  this  camp,  but  still  within  the  city  limits,  while 
the  Forty-ninth  Iowa  and  the  Second  and  Fourth  Virginia  were 
removed  to  a  site  near  Long  Branch,  some  3  miles  distant.     The  first 


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133 

camp  site  of  this  division  was  not  objectionable  in  dry  weather,  but 
wlien  the  rains  began  the  location  of  the  Forty-ninth  and  Fiftieth 
Iowa,  Fourth  Virginia  and  First  Wisconsin  became  undesirable, 
owing  to  the  lack  of  natural  drainage  and  their  proximity  to  the 
swampy  ground.     (See  sketch  map.) 

The  water  supply  was  piped  from  the  city  supply  to  each  company 
street,  and  was  of  excellent  quality  and  very  abundant. 

Pits  were  dug  for  the  reception  of  kitchen  slops,  but  as  the  camp 
was  within  the  city  limits,  pits  for  excreta  were  forbidden.  For  the 
disposal  of  excreta,  therefore,  half  tubs  were  provided,  which  when 
partially  filled  were  hauled  away  on  wagons  by  the  city  authorities 
to  a  dumping  ground,  the  tubs  washed  out  by  hose  and  returned  for 
further  use.  As  earth  was  not  permitted  to  be  used  in  these  tubs, 
their  condition  was  extremely  filthy,  the  contents  being  unprotected 
from  flies  and  frequently  spilled  out  while  being  hauled  away  to  the 
dumping  ground.  The  location  of  the  half  tubs  was  in  many  instances 
in  close  proximitj'  to  the  mess  tents.  (See  regimental  histories,  Sec- 
ond Division.) 

The  amount  of  tentage  was  not  sufficient  for  this  division,  the  com- 
plaint having  been  repeatedly  made  to  us  that,  in  many  regiments, 
eight  men  were  sleei)ing  in  an  A  wall  tent  9  bj^  9  feet.  The  division 
commander  testified  to  the  insufficiency  of  tentage. 

In  considering  the  development  of  tj^phoid  fever  in  this  division, 
then,  we  may  say  that  four  of  the  regiments  imported  the  disease  into 
the  camp  at  Mobile,  Ala.,  and  that  all  of  them  acquired  cases,  few  in 
number,  at  this  camp;  in  just  what  way,  it  has  been  impossible  for 
us  to  determine.  We  can  state,  however,  that  there  does  not  appear 
to  have  been  any  contamination  of  the  water  supply.  Transferred  to 
Miami,  Fla.,  during  the  third  week  in  June,  and  placed  in  a  camp 
which  by  unanimous  testimony  was  undesirable,  both  as  to  the  general 
character  of  the  camp  site  and  the  water  supply,  typhoid  fever, 
although  occurring  in  increased  numbers,  did  not  reach  that  propor- 
tion of  cases  or  that  equal  distribution  in  the  command  that  should 
have  resulted  had  the  water  supplj^  been  contaminated.  To  this  we 
have  repeatedly  called  attention  in  the  histories  of  the  several 
regiments. 

It  is  important  to  observe  that  water  carriage  for  the  disposal  of 
excreta  was  introduced  into  the  camp  at  Miami,  shortly  after  the 
arrival  at  that  point,  for  the  use  oi  four  of  the  six  regiments,  and  that 
ujDon  the  transfer  of  the  division  to  the  camp  at  Jacksonville,  Fla., 
the  same  method  for  the  disposal  of  excreta  was  again  made  use  of 
for  all  of  these  regiments.  In  this  regard  this  division  occupied  an 
exceptional  position  at  Jacksonville,  and  we  shall  later  see  that  typhoid 
fever  was  far  less  prevalent  in  this  division  than  in  the  Second  and 
Third  divisions  of  the  Seventh  Army  Corps. 


134 

GENERAL   DISCUSSION   OF  TYPHOID   FEVER  IN  THE   SECOND    DIVISION^ 
SEVENTH   ARMY   CORPS. 

In  briefly  discussing  the  course  of  typhoid  fever  in  the  Second  Divi- 
sion it  is  important  to  bear  in  mind  that  of  the  nine  regiments  origi- 
nally constituting  this  division,  four  imported  typhoid  fever  into  this 
camp,  viz :  Second  Illinois  Infantry,  First  Wisconsin  Infantry,  Second 
Virginia  Infantry,  and  Fourth  Virginia  Infantry.  It  is  probable  that 
the  First  North  Carolina  Infantry  also  imported  the  disease. 

During  the  period  from  May  23,  1898,  when  these  regiments  began 
to  arrive,  until  June  30,  we  observe  that  77  cases  of  typhoid  fever  have 
occurred  in  this  division  in  a  strength  of  10,759  men,  or  at  the  rate  of 
7.15  cases  per  1,000  of  mean  strength.  We  further  note  that  58  of 
these  cases  occurred  in  regiments  that  imported  the  disease,  and  13- 
additional  cases  in  the  First  North  Carolina  Infantry,  which  we  have 
reason  to  believe  also  imported  typhoid  fever.  On  the  other  hand, 
only  six  cases  had  occurred  in  the  three  regiments  that  did  not  import 
typhoid  fever. 

By  reference  to  the  graphic  charts  for  this  division,  however,  it  will 
be  plainly  seen  that  while  all  regiments  had  cases  of  typhoid  fever  by 
June  30,  the  disease  affected  only  certain  companies  in  different  regi- 
ments. Thus,  in  the  Second  Illinois  seven  companies  had  no  cases  of 
typhoid  fever,  in  the  Fiftieth  Iowa  nine  companies  had  no  cases,  in 
the  First  North  Carolina  three  companies  had  none,  in  the  Second 
Virginia  three  companies  had  none.  As  all  the  companies  of  the  sev- 
eral regiments  had  the  same  water  supplj^,  it  is  impossible  to  look  to  a 
contamination  of  the  water  as  the  source  of  infection. 

The  infection  having  been  established  in  all  regiments  by  June  30, 
we  find  that  during  the  next  fifteen  days  the  cases  have  risen  to  110, 
or  at  the  rate  of  10. 2  cases  jDer  1,000  of  mean  strength.  This  rate 
steadily  rises  for  the  period  July  16  to  31,  there  having  occurred  197 
cases,  or  at  the  rate  of  18.3  per  1,000  men,  thus  giving  for  the  month 
of  July  28.53  cases  per  1,000  men,  as  against  a  rate  of  7.24  for  June. 

The  worst  infected  regiment  in  this  division  during  July  was  the 
First  Wisconsin  Infantry,  which  had  89  cases;  the  least  infected  regi- 
ment, with  11  cases,  was  the  Forty-ninth  Iowa.  Regiments  whose 
camp  sites  and  general  surroundings  appeared  to  be  the  same,  except 
that  the  dust  from  the  shell  road,  along  which  the  scavenger  wagons 
passed,  was  supposed  to  have  been  concerned  in  spreading  infection 
among  the  men  of  the  former  regiments. 

We  have  already,  in  a  careful  examination  of  this  question  (see 
history  of  the  First  Wisconsin),  shown  that  however  natural  and 
plausible  this  theory  of  dust  infection  may  have  appeared,  the  facts 
do  not  substantiate  it.  While  it  is  possible  that  isolated  cases  were 
due  to  this  mode  of  infection,  it  can  not  be  assigned  as  the  chief 
cause. 

During  the  month  of  August  we  find  a  steady  increase  in  the  num- 


135 

ber  of  cases  of  t^^plioid  fever,  all  regiments  except  the  First  North 
Carolina  showing  an  increase  of  cases,  although  unequal,  so  that  for 
this  month  858  cases  are  recorded.  The  rate  per  1,000  men  has,  there- 
fore, risen  from  28.58  for  July  to  79.74  for  August.  We  again  call 
attention  to  the  graphic  charts  which  show  that  the  disease  was  man- 
ifested by  a  series  of  company  epidemics  which  varied  much  in  their 
time  of  commencement,  their  course,  and  time  of  ending. 

On  August  1  two  regiments,  viz,  the  First  Wisconsin  and  Fiftieth 
Iowa,  were  removed  from  their  infected  camp  sites  and  placed  upon 
higher  ground  about  1  mile  west  of  their  former  camp.  On  August 
14  the  Second  and  Fourth  Virginia  and  the  Forty-ninth  Iowa  were 
also  moved  to  a  camp  near  the  St.  Johns  River,  about  3  miles  north- 
east from  the  first  site.  We  have  been  unable  to  observe  that  any 
reduction  of  cases  of  fever  resulted  from  this  move.  On  the  con- 
trary, we  find  a  marked  increase  of  cases  in  the  First  Wisconsin, 
Fiftieth  and  Forty-ninth  Iowa,  and  no  reduction  in  cases  in  the  two 
Virginia  reaiuients.  Since  each  of  these  carried  along  with  them 
many  men  already  infected,  together  with  infected  clothing  and  bed- 
ding, the  result  is  just  what  we  should  have  been  led  to  expect. 

On  August  8  the  Ninth  Illinois  Infantry  arrived  from  its  State  camp 
at  Springfield,  111.,  and  was  placed  near  the  Fiftieth  Iowa,  1  mile  west 
of  the  old  camp.  This  regiment  imported  typhoid  fever,  and  had 
prior  to  the  end  of  August  22  cases  of  this  disease  in  its  Florida  camp. 
Like  the  other  regiments  of  this  division,  it  was  provided  with  half 
tubs  for  the  disposal  of  excreta. 

The  beginning  of  September  (the  fourih  month  of  the  Jacksonville 
encampment)  found  the  regiments  of  the  Second  Division  occupying 
three  distinct  camps,  as  follows:  The  original  camp  site  by  the  Second 
Illinois,  First  North  Carolina,  and  the  Second  New  Jersey,  forming 
the  First  Brigade;  the  Second  Brigade,  consisting  of  the  First  Wis- 
consin, Fiftieth  Iowa,  and  Ninth  Illinois,  located  1  mile  west  of  the 
old  camp ;  and  the  Third  Brigade,  consisting  of  the  Second  and  Fourth 
Virginia  and  Fortj^-ninth  Iowa,  occupying  a  new  site  3  miles  north- 
east of  the  old  camp.  Of  the  regiments  which  continued  to  occupy 
these  camj)  sites  during  September,  typhoid  fever  increased  steadil}^  in 
all.  Three  regiments  were  moved  during  the  month,  viz :  Second  New 
Jersey  to  Pablo  Beach  on  September  2 ;  First  Wisconsin  to  its  State 
encampment  on  September  7;  and  the  Fiftieth  Iowa  also  to  its  State 
encampment  on  September  17.  In  all  of  these  regiments  there  is  an 
apparent  great  reduction  in  cases  of  tyjjhoid  fever  following  their 
respective  moves;  but  this  is  due  in  the  cases  of  the  First  Wisconsin 
and  Fiftieth  Iowa  to  absence  of  any  records  after  the  date  of  their 
departure.  In  the  case  of  the  Second  New  Jersey  there  was  a  reduc- 
tion in  cases  from  156  for  August  to  106  for  September,  and  this  reduc- 
tion may  be  real,  as  the  regiment  was  occupying  a  salubrious  site  on 
the  beach  at  Pablo,  Fla. ,  during  the  entire  month  of  September.  To 
the  defectiveness  of  the  records  from  the  Pablo  Beach  Hospital  was 


136 

probably  partly  due  this  decrease  in  cases  of  tj^phoid  fever.  In  cal- 
culating the  progress  of  typhoid  fever  for  the  month  of  September  we 
therefore  only  include  those  regiments  which  were  not  subjected  to 
any  movement  during  the  month.  We  thus  find  in  a  mean  strength 
of  7,222  men  733  cases  of  typhoid  fever,  or  a  rate  of  100.15  cases  per 
1,000  of  strength,  as  compared  with  79.74  per  1,000  for  August.  Look- 
ing at  the  charts  of  the  individual  regiments,  we  find  that  all  show  a 
marked  increase  of  cases,  except  the  Second  Virginia,  in  which  there 
are  recorded  the  same  number  of  cases  for  September  as  for  August, 
but  there  are  no  records  of  this  regiment  for  the  last  days  of  Septem- 
ber. The  largest  increase  occurred  in  the  Fortj'-ninth  Iowa — 295 
cases  as  against  117  for  August.  When  we  recall  that  this  regiment 
had  been  given  a  new  camp  site  on  August  11,  and  that  its  method  of 
disposal  of  excreta  had  been  changed  from  the  very  objectionable  and 
much  criticised  "tub  system"  to  that  of  dug  pits,  and  that  each 
soldier  was  required  to  cover  his  stool  immediately,  under  the  eye  of 
a  sentinel,  we  are  inclined  to  admit  that  there  must  be  other  means 
concerned  in  the  propagation  of  typhoid  fever  in  militaiy  camps  than 
the  transference  of  the  specific  bacillus  by  flies.  The  infection  which 
had  taken  such  a  hold  on  this  regiment  was  still  manifested  by  the 
occurrence  of  133  cases  during  October,  the  first  25  days  of  which 
were  spent  in  the  same  camp.  By  reference  to  the  graphic  chart  it 
will  be  seen  that  the  course  of  the  disease  was  characterized  by  com- 
panj'^  epidemics,  and  that  while  Companies  E,  K,  and  L  had  but  1,  3, 
and  5  cases,  respectively,  other  eomj)anies  were  much  afflicted.  In 
the  Ninth  Illinois  Inf antiy ,  typhoid  fever  continued  to  prevail  during 
October,  there  being  recorded  82  cases  against  101  for  September. 
The  same  remark  may  be  applied  to  the  Second  Illinois,  the  First 
North  Carolina,  and  the  Fourth  Virginia,  the  only  remaining  regi- 
ments of  the  Second  Division  at  Camp  Cuba  Libre,  although  there 
was  a  marked  reduction  in  the  number  of  cases. 

During  the  last  week  in  October,  1898,  the  Second  Division  was 
transferred  to  Savannah,  Ga.  (For  details  of  the  later  occurrence  of 
typhoid  fever,  see  regimental  histories.) 

Table  shoioing  for  the  regiments  of  the  Second  Division  of  the  Seventh  Army  Corps, 
assembled  at  Jacksonville,  Fla. ,  the  mortality  and  morbidity  from  typhoid  fever. 


Mean 
strength. 

Cases  of  typhoid 
fever. 

Deaths 

from 

typhoid 

f ever . 

Deaths 

Regiments. 

Certain. 

Certain 

and 
probable. 

from  all 
diseases. 

2d    Illinois- _ - 

1,095 
1,164  1 
1,153 
1,232 
1.097 
1,288  ; 
1,220  i 
1,274 

1,236    ; 

253 
147 

185 
209 
164 
1.53 
105 
135 
378 

341 
227 
318 
311 
253 
248 
1.52 
231 
612 

18 
16 
29 
46 
33 
18 
17 
21 
50 

22 

1st  North  Carolina                

20 

2d    New  Jersey  ._ 

1st  Wisconsin 

50th  Iowa          ..          .              ...        

32 

48 
33 

9th  Illinois 

28 

2d    Virginia .  .                       ..       .        .. 

20 

28 

49th  Iowa 

50 

Total 

10,7.59 

1,729 

2,693 

248 

281 

137 

Table  showing  for  the  regiments  of  the  Second  Division  of  the  Seventh  Army  Corps, 
etc, ,  the  mortality  and  morbidity  from  typhoid  fever — Continued. 


Deaths    from 
fever    in    100 
cases  of— 

Per- 
centage 
of  deaths 

from 
typhoid 
to  deaths 
from 
all  dis- 
eases. 

Morbidity   of 
typhoid    fever 
in   1,000    mean 
strength. 

Deaths 

from 

typhoid 

Regiments. 

Certain 
typhoid. 

• 

Certain 
and 

proba- 
ble. 

For 
certain 
cases  of 
typhoid. 

For  cer- 
tain and 
probable 
cases  of 
typhoid. 

fever  in 
1,000 
mean 

strength. 

7.11 
10.88 
15. 67 
23.00 
20.13 
11.76 
16.19 
15.55 
13.33 

5.37 

7.04 

9.11 

14.79 

13.04 

7.25 

11.18 

9.09 

8.16 

81.81 
80.00 
90.63 
95.83 

100.00 
64.28 
85.00 
75. 00 

100.00 

231. 05 
136.38 
160.45 
169. 64 
149.49 
118. 80 
86.06 
105. 96 
305. 83 

311.41 
195. 01 
375. 80 
353.43 
230. 63 
193. 54 
124. 59 
181.31 
495. 14 

16. 43 

1st  North  Carolina 

13  74 

25. 15 

1st  Wisconsin .'. 

37.33 

80.08 

9th  Illinois       .                .                  .        . 

13.97 

3d    Virginia. 

13.93 

4tli  Virginia .- 

49th  Iowa 

16.48 
40.49 

Total 

14.34 

9.20 

•88.35 

160. 70 

250.30 

23.05 

CHAPTER  XII. 

TYPHOID    FEVER    IN    THE    THIRD     DIVISION,    SEVENTH    ARMY 

CORPS. 

Commands, — Second  Mississippi  Infantry,  Fourth  Illinois 
Infantry,  First  South  Carolina  Infantry,  Second  U.  S.  Volun- 
teer Cavalry,  Third  Nebraska  Infantry,  One  hundred  and 
sixty-first  Indiana  Infantry,  Sixth  Missouri  Infantry,  Second 
South  Carolina  Infantry. 


THE   THIRD    DIVISION    CAMP    AT   JACKSONVILLE,    FLA. 

This  division  was  encamped  at  Panama  Park,  about  4  miles  north- 
east of  Jacksonville.  The  ground  selected  for  the  camp  was  elevated 
and  rolling,  thus  admitting  of  good  natural  drainage. 

The  water  supply  was  obtained  from  a  deep  artesian  well  (800  feet) 
at  Panama  Park,  and  was  piped  under  constant  pressure  to  eveiy 
company  street.     Its  quality  was  therefore  unexceptionable. 

For  the  disposal  of  garbage  and  excreta  pits  were  dug  in  the  sandy 
soil  to  a  depth  of  about  G  feet.  The  contents  were  covered  with  earth 
and  lime  about  three  times  daily.  During  the  latter  part  of  the 
encampment  each  soldier  was  required  to  cover  his  stool  imme- 
diately with  dry  earth,  under  the  supervision  of  a  sentinel  stationed 
at  the  sink. 

The  regimental  histories  which  follow  must  be  consulted  for  the 
location  of  sinks,  which  differed  much  in  distance  from  the  mess  tents 
in  different  regiments.  In  the  case  of  the  Second  Mississippi,  Third 
Nebraska,  and  One  hundred  and  sixty-first  Indiana  these  pits  were 
dangerously  close  to  the  kitchens  and  mess  tents. 

As  regards  general  location  this  camp  was  preferable  to  that  occu- 
pied by  the  Second  Division. 


138 

GENERAL  PROGRESS   OF   TYPHOID   FEVER  IN  THE   THIRD   DIVISION. 

We  have  so  fully  reviewed,  in  connection  with  each  regiment's  his- 
tory, the  course  of  typhoid  fever  that  little  remains  to  be  said  con- 
cerning the  progress  of  the  disease.  We  observe  in  this  division  that, 
seven  of  the  eight  regiments  imported  cases  of  typhoid  fever  into  their 
camp  at  Panama  Park.  The  first  regiment  to  arrive  at  this  camp  was 
the  Second  Mississippi  Infantry  (June  21),  which  imported  9  cases 
from  its  camp  at  Jackson,  Miss.  The  Second  U.  S.  Volunteer  Cavalry, 
arriving  June  28,  did  not  import  typhoid  fever.  With  this  excep- 
tion, however,  the  remaining  regiments,  which  came  in  July,  August, 
and  September,  all  brought  cases  of  the  disease.  It  is  not  necessary, 
therefore,  to  look  to  other  sources  for  the  origin  of  typhoid  fever  in 
this  division.  Indeed,  the  opportunity  for  infection  outside  of  the 
camp  was  very  slight.  Once  imported,  the  course  of  the  disease  in 
the  individual  regiments  did  not  differ  from  its  progress  in  other 
divisions  of  this  corps,  or  in  the  First,  Second,  Third,  or  Fourth  Corps, 
heretofore  treated  of.  With  few  cases  during  the  first  month  after 
its  introduction,  its  progress  was,  as  a  rule,  steady  during  the  second 
and  third  months,  being  marked  by  company  epidemics  of  greater  or 
less  severity.  -  We  note  that  in  the  case  of  the  First  South  Carolina 
Infantrj^,  which  joined  this  division  on  July  30,  1898,  typhoid  fever 
made  but  slight  progress,  although  the  conditions  for  the  propagation 
of  the  disease"  appeared  not  to  differ  from  those  by  which  all  other 
regiments  of  this  division  were  surrounded.  We  have  been  unable 
to  offer  any  explanation  for  this  partial  freedom  from  typhoid  fever 
in  this  regiment. 

There  was  nothing  in  the  course  of  the  disease  in  any  of  the  regi- 
ments that  indicated  any  contamination  of  the  regimental  or  company 
water  supply. 

Table  showing  for  the  regiments  of  the  Third  Division  of  the  Seventh  Army  Corps, 
assembled  at  Jacksonville,  Fla.,  the  mortality  and  morbidity  from  typhoid  fever. 


j  Percent- 

A 

Certain 

and 

probable 

cases  of 

typhoid 

fever. 

Deaths '    age  of 

Morbid- 

Deaths 

Deaths  j^^T^ 
from    H®™ 

from  1   deaths 
ty-      from  ty- 

ity of 
typhoid 

from 
typhoid 

Regiments. 

s 

ty- 
phoid 
fever. 

all  dis- 
eases. 

phoid 
fever 
in  100 

phoid 

fever  to 

deaths 

fever  in 
1,000 
mean 

fever 

in  1,000 

mean 

OJ 

cases. 

from  all 

strength. 

strength. 

S 

■ 

diseases. 

4th  Illinois     

1,194 
1,304 

238 
134 

20 
14 

25 
15 

8.40 
10.44 

80.00 
93.33 

199. 32 
102.  76 

16.75 

161st  Indiana 

10.73 

2d    Mississippi. 

1,317 

118 

17 

22 

14.40 

77.27 

96.95 

13.96 

1,149 

1,263 

945 

286 

280 

85 

19 

37 

8 

23 
30 
14 

6.64 
9.64 
9.41 

86.36 
90.00 
57.14 

248. 91 

221. 87 

89.94 

16.53 

21.39 

2d    South  Carolina 

8.46 

2d   Vohinteer  Cavalry  . . 

919 

151 

15 

18 

9.93 

83.33 

164. 30 

16.33 

Total    

7,990 

1,292 

120 

146 

9.28 

82.19 

161. 70 

15.01 

139 

MALARIAL  DISEASES  IN  THE  SEVENTH   ARMY  CORPS. 

At  the  request  of  this  board  Dr.  James  Carroll,  acting  assistant 
surgeon,  U.  S.  Army,  was  sent  to  Camp  Cuba  Libre  for  the  purpose 
of  determining,  by  blood  examinations,  whether  malarial  diseases  were 
as  prevalent  as  the  diagnosis  of  regimental  and  division  hospital 
medical  officers  would  indicate.  The  following  report  is  submitted 
entire : 

Washington,  D.  C,  September  19,  1898. 

Sir:  I  have  the  honor  to  submit  the  following  report  of  work  done  at  Camp 
Cuba  Libre,  Jacksonville,  Fla.,  under  paragraph  32,  Special  Orders,  No.  206,  Adju- 
tant-General's Ofi&ce,  September  4,  1898,  and  instructions  received  personally 
from  you. 

I  reported  at  the  Second  Division  hospital  on  the  afternoon  of  September  5,  and 
on  the  next  morning  drew  blood  from  16  patients  for  the  purpose  of  applying  the 
Widal  test  as  the  first  step  in  determining  the  nature  of  the  fevers  prevailing 
there.  Brief  notes  were  taken  of  the  dates  of  admission,  history,  and  prominent 
features  in  each  case.  Of  the  16  specimens  taken,  14  gave  a  positive  reaction  next 
day;  1  was  negative,  but  suspicious,  from  the  fact  that  motility  was  impaired  and 
a  small  number  of  the  bacilli  showed  a  tendency  to  agglutinate;  and  1  was  entirely 
negative.  The  case  from  which  the  latter  was  taken  had  only  been  admitted  to 
the  hospital  on  the  preceding  day,  with  an  evening  temperature  of  104°  and  a 
previous  history  of  epistaxis. 

September  8  I  drew  blood  from  45  patients  in  another  ward,  making  no  selec- 
tions and  taking  them  in  regular  order.  Three  of  these  were  thought  by  the 
physician  in  charge  of  them  to  be  probable  cases  of  malarial  fever.  One  was 
supposed  to  have  had  a  frank  chill,  with  a  regular  ague  shake  every  other  day 
since  his  admission,  September  1.  He  had  been  sick  in  quarters  seven  days  pre- 
viously, and  his  tongue  presented  the  appearance  of  that  of  a  typhoid- fever  patient. 
Another,  admitted  to  hospital  August  17,  had  been  sick  in  quarters  two  weeks. 
The  third  had  been  sick  nearly  two  months,  three  weeks  of  that  time  in  quarters, 
doing  light  duty.  He  was  taken  sick  on  the  second  or  third  day  after  he  arrived 
in  camp,  with  malaise  and  fever,  with  sweating,  but  had  never  had  a  chill. 
Examinations  of  the  fresh  blood  for  malarial  parasites  in  these  cases  were  nega- 
tive, but  all  3  reacted  positively  to  the  Widal  test.  Of  the  45  samples  of  blood 
taken,  39  gave  a  positive  reaction,  3  gave  a  reaction  that  was  incomplete,  and 
3  negative.  Those  noted  at  the  time  as  incomplete  gave  what  appeared  to  be  a 
positive  reaction  next  morning.  Of  the  3  negative  specimens,  1  showed  a  positive 
reaction,  with  distinct  clumping,  next  morning;  the  other  2  remained  unchanged. 
One  of  these  negative  cases  gave  a  positive  reaction  with  a  second  specimen 
drawn  September  16,  the  other  still  remaining  negative,  so  that  out  of  45  con- 
secutive cases  only  1  remained  absolutely  negative. 

My  attention  was  next  directed  to  the  receiving  ward  of  this  hospital,  from 
whence  the  patients  were  distributed,  in  the  hope  of  securing  malarial  cases 
immediately  upon  admission,  but  only  a  few  promising  ones  could  be  found.  One 
man  of  the  reserve  ambulance  company  was  doing  duty  with  an  evening  tempera- 
ture of  103^-^  and  morning  temperature  of  100°.  He  had  a  large,  pale,  furred 
tongue,  and  gave  a  history  of  malaise  for  about  two  weeks.  Examinations  for 
malarial  parasites,  negative;  widal  test,  negative.  Another  case,  examined 
September  12,  was  admitted  to  hospital  September  11  with  an  evening  tempera- 
ture of  104°  and  morning  temperature  of  102^,  Quinine  had  been  withheld  and 
an  examination  was  renuested  for  malarial  infection.  History:  Sick  in  quarters 
six  days;  feeling  badly  nine  days  before  going  on  sick  report.     His  tongue  is 


140 

slightly  coated  and  quite  red  at  the  tip  and  edges.  Examination  for  malaria, 
negative;  widal  test,  negative.  Still  another,  a  lieutenant,  who  continued  to 
perform  his  duties,  complains  of  headache  and  soreness  of  the  bowels  for  several 
days,  with  anorexia.  He  had  no  chill;  his  tongue  is  moist  and  furred,  edges 
slightly  reddened.  Quinine  had  been  withheld  and  an  examination  of  his  blood 
for  malarial  parasites  requested.  Result,  negative:  Widal  test,  negative.  When 
I  left  the  camp,  four  days  later,  I  was  told  that  his  condition  was  about  the  same, 
and  appendicitis  was  suspected.  I  believe  he  was  in  the  prodromal  stage  of 
typhoid  fever. 

I  was  next  called  to  a  supposed  case  of  tertian  intermittent  fever  from  which 
quinine  was  said  to  have  been  withheld.  He  gave  a  history  of  having  been  sick 
ten  days  or  two  weeks  before  his  admission  to  sick  report  two  days  ago.  He  had 
had  chilly  sensations,  followed  by  fever  and  sweating,  at  irregular  intervals. 
Took  quinine  when  he  was  first  feeling  badly,  and  is  now  taking  gr.  v  every  4 
hours.     Examinations  for  malaria,  negative;  Widal  test,  positive. 

I  was  shown  a  case  of  considerable  interest  on  September  11.  Private  A.  G., 
Company  K,  Forty-ninth  Iowa  Infantry,  admitted  to  hospital  September  7,  had 
been  sick  in  quarters  one  week.  History  of  headache,  pains  in  the  back,  and  epis- 
taxis  occurring  several  times.  Pulse  very  slow,  about  50  to  60.  There  is  much 
depression,  a  slight  mental  hebetude,  and  he  has  vomited  blood  several  times. 
There  are  no  signs  of  jaundice.  Examinations  of  fresh  blood  for  malarial  para- 
sites, negative.  Widal  test  gives  prompt  arrest  of  motility  and  slight  agglutina- 
tion at  the  end  of  an  hour.  I  ought  to  have  stated  that  his  temperature  was  sub- 
normal and  there  was  a  constant  hiccough.  Patient  died  at  9  a.  m.  September  13, 
and  at  the  autopsy,  which  I  witnessed,  there  were  found  thickened,  in.iected,  and 
ulcerated  Peyer's  patches  in  the  ileum  and  appendix;  swollen  glands  in  the  mes- 
entery and  meso-appendix;  moderate  splenic  tumor;  liver  but  little  changed  from 
normal.  The  mucous  membrane  of  the  stomach  was  intensely  injected,  and  the 
organ  contained  a  thin,  dark,  bloody  fluid:  the  intestine  also  contained  a  tarry 
material.  Very  marked  changes  were  apparent  in  the  kidneys,  which  appeared  to 
.  be  the  seat  of  an  acute  parenchymatous  nephritis.  Both  were  enormously  swollen, 
soft,  and  their  surfaces  were  dotted  with  enlarged  stellate  veins.  The  cortex  of 
each  was  very  much  increased  in  thickness,  grayish,  cloudy,  and  marked  with 
dark-red  pin-head  spots  (Malphigian  bodies)  over  the  cut  surface.  The  pyramids 
were  darkly  congested.  His  urine  was  said  to  have  shown  about  one-third  of  its 
volume  of  albumen. 

The  receiving  ward  proving  very  unfruitful  in  producing  cases  of  malaria,  I 
deemed  it  best  to  apply  the  Widal  test  in  conjunction  with  an  examination  of  the 
fresh  blood  for  malarial  parasites,  where  there  seemed  to  be  the  slightest  indica- 
tion for  it,  to  a  series  of  cases  in  any  one  of  the  general  wards,  all  of  which  were 
practically  filled  with  patients  suffering  from  fever  of  a  remittent  or  continued 
type.  At  the  same  time  I  made  it  known  that  I  was  ready  and  anxious  to  exam- 
ine the  blood  of  any  patient  known  or  suspected  to  be  suffering  from  malarial 
infection.  These  examinations,  with  the  results,  are  shown  in  tabulated  form  in 
Appendix  A. 

On  September  12  I  visited  the  hospital  of  the  Third  Division,  Seventh  Army 
Corps. 

The  first  ward  studied  was  under  the  charge  of  a  contract  surgeon  from  Indiana, 
who  had  been  so  much  impressed  by  the  assertions  of  the  local  physicians  as  to  the 
prevalence  of  malarial  disease  that  he  regarded  all  of  his  cases  as  malarial  and 
treated  them  without  discrimination  as  such.  No  temperature  charts  or  records 
of  the  histories  of  the  cases  were  kept  by  him.  and  he  had  no  data  to  offer  beyond 
the  date  of  admission  to  hospital.  Upon  eliciting  histories  from  the  patients  in  his 
presence,  and  pointing  out  the  rose  spots  and  other  diagnostic  signs  of  typhoid 
fever,  he  admitted  that  some  of  the  cases  "might  be  typhoid  fever,  but  was  con- 


141 

fident  there  was  a  strong  malarial  element  in  all  of  them."  To  eliminate  this  he 
was  administering  to  all  classes  of  patients,  both  mild  and  severe,  dr.  iv  of  War- 
burg's tincture  every  4  hours. 

The  cases  in  this  ward  were  so  clearly  typhoid  fever,  and  not  malarial,  thatfresh 
blood  examinations  were  not  made,  and  drops  were  taken  for  the  Widal  test  only 
from  7  of  the  least  typical  ones.     For  the  results,  see  cases  1-7,  Appendix  B. 

The  next  ward  visited  was  under  the  charge  of  a  volunteer  medical  ofiicer.  He 
was  in  doubt  about  the  diagnosis  of  many  of  his  patients,  but  was  confident  many 
of  them  were  malarial.  He  was  preparing  carefully  written  histories  and  tem- 
perature charts  of  all  his  cases.  He  volunteered  the  statement,  however,  that 
nearly  everj^  one  of  his  fever  patients  had  been  bitten  by  some  unknown  insect, 
but  the  bites,  he  said,  were  not  at  all  like  the  rose  spots  of  typhoid  fever.  He 
could  not  name  or  describe  the  insect,  nor  could  he  explain  why  the  so-called 
"  bites  "  appeared  only  upon  the  trunk,  and  seldom  or  never  upon  the  extremities. 
Examination  disclosed  the  characteristic  roseola,  and  the  histories  and  symptoms 
of  the  patients  all  pointed  to  typhoid  fever,  in  mild  as  well  as  severe  forms.  Exam- 
ination of  blood  in  nearly  all  of  these  cases  was  clearly  not  called  for,  so  plainly 
were  the  diagnoses  established  by  the  clinical  examination.  Drops  of  blood  were 
taken  from  a  few  (6)  of  the  least  typical  cases  at  the  surgeon's  request.  Three  of 
them  were  doubtful  cases,  and  the  others  were  supposed  to  be  cases  of  malarial 
fever.  I  drew  blood  from  only  13  patients  at  this  division  hospital,  applying  the 
Widal  test  to  all  of  them,  and  in  2  instances  the  fresh  blood  was  examined  for 
malarial  parasites  with  negative  result.  Of  the  13  tests  for  the  typhoid  reaction, 
12  proved  positive  and  only  1  negative,  and  the  patient  from  whom  the  negative 
specimen  was  procured  showed  the  unmistakable  roseola. 

The  third  ward  visited  was  in  charge  of  a  contract  surgeon  with  a  foreign 
accent,  but  who  had  received  his  medical  education  in  the  United  States.  I  asked 
him  if  his  ward  contained  any  cases  of  malarial  fever,  to  which  question  he  replied 
very  promptly  and  with  emphasis,  "Not  one."'  Upon  further  interrogation  he 
stated  that  of  the  50  patients  under  his  control  46  were  typhoid  fever  and  4,  as  yet, 
undetermined.  His  cases  differed  not  at  all  from  those  in  the  adjoining  wards, 
and  it  was  truly  refreshing  to  meet  such  a  man  whose  confidence  showed  that  he 
spoke  from  firm  conviction. 

On  September  13  I  visited  the  Third  Division  hospital.  Surgeon  Munday  tempo- 
rarily in  charge.  1  inquired  for  any  cases  of  malarial  fever,  but  none  could  be 
found,  though  I  heard  the  diagnosis,  "Malarial  remittent  fever,  mild  form," 
called  several  times  in  the  office  by  men  who  appeared  to  be  comparing  monthly 
reports  of  sick  and  wounded.  I  was  told  that  the  cases  were  chiefly  typhoid 
fever,  dysentery,  and  diarrhea.  I  was  taken  to  1  patient  whose  diagnosis  was 
regarded  as  doubtful,  probably  a  case  of  malarial  fever: 

F.  O.,  Company  A,  First  Alabama,  admitted  to  hospital  September  7,  sick  for 
about  eight  days  previously.  There  were  several  small  rose  spots,  disappearing 
on  light  pressure,  over  the  chest  and  abdomen.  It  was  supposed  that  a  segment- 
ing malarial  parasite  (vacuolated  leucocyte?)  had  been  seen  in  the  patient's  blood 
that  morning.  I  did  not  think  it  necessary  to  examine  the  fresh  blood  for  mala- 
rial parasites  but  obtained  a  drop  or  two  for  the  Widal  reaction.  Tested  next 
morning  it  gave  a  positive  reaction.  This  was  the  only  case  of  continued  or 
remittent  fever,  so  far  as  I  could  learn,  that  was  not  recognized  as  typhoid  fever. 

Three  cases  of  sui^posed  malarial  fever  were  brought  into  the  hospital  from  one 
of  the  regiments  during  my  visit.  They  were  cases  recently  admitted  to  sick 
report  and  had  not  as  yet  been  treated  in  bed. 

1.  C.  D. ,  Company  F,  First  Texas.  Has  been  ailing  for  about  a  month.  He  had 
diarrhea  for  some  time.  He  had  a  chill  yesterday  and  had  taken  no  quinine  since 
the  chill.     Examination  for  malarial  parasite,  negative;  Widal  test,  negative. 

2.  Gr.  R.,  Company  D,  First  Texas.     Sick  about  two  and  one-half  days.     Has 


142 

had  no  chill,  but  has  felt  badly  for  two  days  before  going  on  sick  report.  Took 
quinine  gr.  vi  to-day  at  1  p.  m.  Examination  for  malarial  parasite,  negative: 
Widal  test,  negative. 

3.  R.  W,  Company  F,  First  Texas.  Has  been  sick  a  day  and  a  half.  Has  had 
only  fever;  no  chill  and  no  sweating.  Has  not  taken  any  quinine.  Examination 
for  malarial  parasite,  negative;  Widal  test,  positive. 

It  is  remarkable  that  1  case  in  3  gave  a  positive  reaction  so  early  in  the  disease, 
and  It  recalls  3  similar  supposed  cases  of  malaria  which  were  all  the  cases  of  fever 
I  could  find  at  the  camp  of  the  Twelfth  Pennsylvania  Infantry  at  Camp  Alger. 
They  were  all  sick  in  quarters  only,  and  were  believed  to  be  convalescent  from 
mild  attacks  of  malarial  fevers.  I  transcribe  verbatim  from  my  notes  made  at 
the  time. 

Camp  Alger,  August  24,  1898. 

1.  W.  A.  G-.,  Company  E,  Twelfth  Pennsylvania.  Chilly  sensations  followed 
by  fever  is  the  only  history.  Examination  for  malarial  parasites,  made  at  once, 
negative.     August  2o,  1898,  Widal  test,  positive;  good  reaction. 

•'2.  H.  C.R.,  Company  E,  Twelfth  Pennsylvania.  Has  had  a  number  of  frank 
chills,  followed  by  fever  and  sweating.  This  was  the  history  given  by  the  man 
himself,  who  said  he  had  had  regular  ague  shakes.  Examination  for  malarial 
parasites,  made  at  once,  negative.  August  25,  1898,  Widal  test,  positive  reaction, 
typical. 

"3.  H.  W.  S..  Company  E.  Twelfth  Pennsylvania.  Gives  a  history  of  chilly 
sensations  followed  by  malaise  and  a  mild  fever.  Examination  for  malarial  para- 
sites, made  at  once,  negative.     August  25.  1898,  Widal  test,  negative." 

It  is  worthy  of  note  that  in  a  camp  of  a  whole  regiment  the  3  cases  came  from 
the  same  company. 

To  return  to  camp  Cuba  Libre.  Having  been  told  by  the  chief  surgeon  of  the 
Third  Division  hospital  that  a  considerable  number  of  cases  of  malarial  fever  had 
been  reported  by  the  medical  officers  of  the  Second  U.  S.  A^olunteer  Cavalry,  I  made 
a  special  trip  to  the  camp  of  that  regiment.  September  14,  for  the  purpose  of  examin- 
ing any  cases  of  malaria  that  could  be  found.  I  saw  the  junior  medical  officer, 
who  stated  that  he  had  sent  a  patient  to  hospital  an  hour  previously  who,  he  was 
certain,  was  a  case  of  malarial  fever,  and  to  whom  quinine  had  not  been  adminis- 
tered. Besides  this  patient  the  captain  (medical  officer)  showed  me  another 
patient  diagnosed  malarial  fever,  and  these  were  all  that  he  had  of  that  class  of 
cases. 

1.  E.  J. ,  Troop  H,  Second  Volunteer  Cavalry,  just  admitted  to  hospital.  Has 
been  feeling  badly  for  two  weeks.  Gives  a  history  of  pains  in  back  and  limbs, 
diarrhea,  soreness  of  bowels.  His  tongue  is  coated,  and  the  edges  are  bright  red. 
Roseola  is  present.     Widal  test,  negative. 

2.  N.E.D.,  Troop  L,  Second  Volunteer  Cavalry,  admitted  to  hospital  Septem- 
ber 13;  to  quarters  September  10.  History  of  headache,  insomnia.  Tongue  coated 
and  with  bright-red  edges.  Examina,tion  f  or  malarial  parasites,  negative;  Widal 
test,  negative. 

Failure  to  obtain  a  positive  reaction  with  the  typhoid  bacillus  early  in  the  dis- 
ease is  no  evidence  that  the  patient  is  not  suffering  from  typhoid  fever.  On  the 
other  hand,  a  failure  to  find  any  of  the  parasites  of  malaria,  with  the  absence  of 
pigmented  leucocytes,  is  positive  evidence  that  the  patient  is  not  suffering  from 
malarial  infection  at  the  time  the  examination  is  made.  The  uniformity  of  the 
results  obtained  in  this  work  has  been  a  revelation  to  me,  and  I  am  more  than  ever 
impressed  with  the  great  value  of  the  Widal  te.st  in  clearing  up  the  diagnosis  in 
doubtful  and  especially  in  atypical  cases  of  typhoid  fever,  provided,  of  coursg,  the 
test  be  not  applied  too  early  in  the  course  of  the  disease.  I  have  been  impressed 
also  by  the  fact  that  cases,  apparently  those  of  malarial  fever,  and  in  which  I 


143 

expected  to  find  the  parasites,  were  absolutely  negative  in  that  regard,  and  gave 
a  positive  reaction  for  typhoid  fever.  I  regard  the  fact  as  conclusively  proven,  by 
the  reports  hereto  appended,  that  the  fever  prevailing  among  the  troops  at  Camp 
Cuba  Libre  was  typhoid  fever,  pure  and  simple.  Many  of  the  cases  were  ambula- 
tory ones,  in  others  the  fever  was  of  an  ephemeral  type.  I  do  not  make  the  state- 
ment that  isolated  cases  of  malaria  did  not  exist  at  the  time  of  my  visit,  but  I  am 
positive  in  the  assertion  that  no  single  case  of  continued  or  remittent  fever  that 
came  under  my  observation  was  due  to  malarial  infection,  for  with  the  means  at 
hand  of  making  an  absolutely  certain  diagnosis,  by  examination  of  the  fresh  blood, 
I  failed  to  discover  a  single  parasite. 

I  invited  Capt.  George  P.  Peed,  assistant  surgeon,  Fourth  Virginia  Infantry, 
who  is  a  graduate  of  the  University  of  Virginia  and  a  post-graduate  student  of 
the  medical  department  of  the  Johns  Hopkins  University,  to  accompany  me  in  my 
visits  to  the  First  and  Third  Division  hospitals,  and  he  can  bear  me  out  in  any  of 
the  general  or  specific  statements  made  herein.  As  he  was  made  familiar  with 
the  practical  application  of  the  Wldal  test,  and  observed  a  number  of  my  prepa- 
rations under  the  microscope,  he  can  also  testify  in  a  general  way  to  the  con- 
stancy with  which  a  positive  result  was  obtained. 

I  was  accorded  every  facility  for  the  prosecution  of  my  work  by  the  surgeon  in 
charge  of  the  Second  Division  hospital,  who  placed  a  hospital  tent  with  tables  and 
other  conveniences  at  my  disposal. 

Very  respectfully,  your  obedient  servant, 

James  Carroll, 
Acting  Assistdnt  Surgeon,  U.  S.  Army. 

Maj.  Walter  E,eed, 

Surgeon,  U.  S.  Army. 

In  this  connection  we  have  endeavored  to  trace  the  protective  influ- 
ence which  such  supposed  malarial  fevers  would  confer  upon  the 
enlisted  men  of  the  Second  and  Third  divisions  of  this  corps.  The 
following  tables  will  give  the  result  of  our  investigations: 

Cases  of  typhoid  fever  among  men  ivith  and  without  preceding  malarial  diseases 
in  the  Second  Division,  Seventh  Army  Corps,  at  Jacksonville,  Fla. 


Begiments. 


2d  niinois 

9thnUnois 

49tliIowa 

oOth  Iowa 

2d   New  .Jersey 

1st  North  Carolina 

2d   Vir^nia 

4th  Virginia 

1st  Wisconsin 

Totals 


Mean 
strength. 


1,095 
1,288 
1,236 
1.097 
1,1.53 
1.164 
1,220 
1,274 
1,232 


Cases 
of  ma- 
lai'ia. 


162 
217 
235 
149 
216 
120 
109 
308 
160 


10,759  I    1,676 


Cases  of  malaria'  .,,.,. 
followed  by  ty- '  ^^'^- 
phoid  fever.     |  uer  of 

men 

with- 
out 


Typhoid  cases 
without  preced- 
ing malaria. 


Num- 
ber of 
cases. 


malarial  'P5!??° 
ing  ma- 
laria. 


0.0 

5.1 
4.7 
1.7 
6.0 
4.2 


5.0 


4.8 


933 
1,071 
1,001 

948 

937 
1,044 
1,111 

966 
1,072 


9,083 


Num- 
ber of 
cases. 


272 
189 
461 
194 
230 
190 
120 
151 


2,044 


In  100 
men  who 
have  not 
had  ma- 
laria. 


29.20 
17.60 
46. 05 
20.50 
24.50 
18.20 
10.80 
15.60 
22.10 


22.50 


Total 

cases 
of  ty- 
phoid 
fever. 


281 
200 
472 
196 
243 
195 
121 
172 
245 


2,125 


That  is.  of  1,676  individuals  who  have  been  treated  for  malarial  fever  81,  or  4.8  per  cent,  sub- 
sequently had  typhoid  fever. 

C5f  9,083  individuals  who  had  not  been  treated  for  malarial  fever  2.044,  or  22.5  per  cent,  had 
typhoid  fever.  ' 

Or,  of  2,125  cases  of  typhoid  fever  81,  or  3.3  per  cent,  had  previously  been  treated  for  malarial 
fever. 

Of  2,125  cases  of  typhoid  fever  2,044,  or  96.7  per  cent,  had  not  been  treated  for  malarial  fever. 


144 


Cases  of  typhoid  fever  among  men  with  or  tvithout  preceding  malarial  diseases  for 
seven  regiments  of  the  Third  Division,  Seventh  Army  Corps,  at  Jacksonville,  Fla. 


Regiments. 


Mean 
strength. 


4th  Illinois 

161st  Indiana. 

2d  Mississippi 

6th  Missouri ...1.. 

3d  Nebraska 

3d   South  Carolina 

2d   Volunteer  Cavalry . 


Total . 


l,19t 
1,304 
1,217 
1,149 
1. 2f>2 
94.5 
919 


',. 


Cases 
of  ma- 
larial 
fevers. 


200 
299 
614 
176 
307 
537 
233 


2,366 


Typhoid  fevers    -.,. 
preceded  by     1  ^um- 
malaria.         i  "er  or 

i    men 

with- 
out 
mala- 


Num- 
ber  of 
cases. 


In  100    j 
menwitli 

preced   l^^f^Ys- 
ingmala-i^il^i,^ 
ria. 


46 


1.5 
3.3 
1.6 
3.9 
1.9 
1.1 
3.0 


1.9 


1,005 
603 
973 
955 

408 
686 


5,634 


Typhoid  fever 
without  preced- 
ing malaria. 


Num- 
ber of 
cases. 


235 
137 

108 

379 

274 

79 

144 


1,246 


In  indi- 
viduals 
without 
malaria. 


23.6 
12.6 
17.9 

28.6 
28.6 
19.3 
20.9 


Total 
cases 
of  ty- 
phoid 
fever. 


238 
134 

118 
286 
280 
85 
151 


1,293 


That  is,  of  3,366  individuals  who  had  been  treated  for  malarial  fever  46,  or  1.9  per  cent,  subse- 
quently had  typhoid  fever. 

Of  5,634  individuals  who  had  not  been  treated  for  malarial  fever  1,346,  or  23.1  per  cent,  had 
typhoid  fever. 

Or,of  1,293  cases  of  typhoid  fever  46,  or  3.5  per  cent,  had  previously  been  treated  for  malarial  fever. 

Of  1,393  cases  of  typhoid  fever  1,346,  or  96.5  per  cent,  had  not  been  treated  for  malarial  fever. 

Combining  tlie  above  tables  for  the  Second  and  Third  divisions,  we 
see  that  of  4,042  individuals  who  had  been  treated  for  these  supposed 
malarial  fevers,  only  127,  or  3.1  percent,  subsequently  had  typhoid 
fever;  whereas  of  14,687  soldiers  who  had  not  experienced  these  milder 
fevers  not  less  than  3,290,  or  22.4  per  cent,  afterwards  contracted 
typhoid  fever. 

These  tables,  taken  in  connection  with  Dr.  Carroll's  careful  obser- 
vations, serve  to  indicate  the  slight  part  played  by  malaria  in  the 
causation  of  fevers  at  Camp  Cuba  Libre. 

RELATION  OF  INTESTINAL  DISORDERS  TO  TYPHOID  FEVER. 

Our  investigations  on  this  point  agree  with  the  results  obtained  in 
our  study  of  the  regiments  of  the  Second  Army  Corps,  aS'  shown  in  the 
following  tables : 

Cases  of  typhoid  fever  among  men  with  and  without  preceding  diarrheal  diseases  in 
the  Second  Division,  Seventh  Army  Corps,  at  JacTcsonville,  Fla. 


Regiments. 


2d   Illinois.- 

9th  Illinois... 

49th  Iowa 

50th  Iowa 

2d    New  Jersey 

1st  North  Carolina . 

2d    Virginia 

4th  Virginia 

1st  Wisconsin 


Total 10,7.59 


1,095 
1,288 
1,236 
1,097 
1, 1.53 
1,164 
1,330 
1,374 
1,232 


Cases  of  diar- 
rheal disease. 


Num- 
ber of 
cases. 


294 
383 
220 
162 
216 
485 
167 
188 
39 


3,056 


Num- 
ber of 
indi- 
vidu- 
als. 


Cases  of  diarrhea   isTum- 
followed  by       ber  of 
typhoid.  men 
with- 
in 100    I     out 
menwith  preced- 


255 
245 
203 
160 
203 
435 
146 
171 
37 


1,853 


Num- 
ber of 
cases. 


164 


preced- 
ing diar- 
rhea. 


10.2 
3.7 

11.8 
5.0 

17.3 
6.0 
9.6 

10.0 

10.  S 


ing 
diar- 
rhea. 


840 

1.043 

1,034 

937 

951 

739 

1,074 

1,103 

1,195 


Typhoid  fever 
without  preced- 
ing diarrhea. 


Num- 
ber of 
cases. 


In  100 
men  hot 
having 
had  diar- 
rhea. 


355 
191 

448 
188 
308 
168 
107 
155 
341 


1,961 


30.4 
18.3 
43.3 
20.1 
31.9 
33.0 
9.9 
14.0 
30.3 


22.3 


Total 
cases 
of  ty- 
phoid 
fever. 


281 
200 
472 
196 
243 
195 
121 
173 
245 

2,125 


That  i.s,  of  1,853  individuals  who  were  treated 'for  intestinal  disorders  164,  or  8.8  per  cent,  subse- 
quently had  typhoid  fever.  ^  „  ,        ^„  „  ,  ■,    j 
Of  8,906  individuals  who  had  not  been  treated  for  intestinal  disorders  1,961,  or  23.3  per  cent,  had 


typhoid  fever. 


Did  rever.  .       ,    ,  ,    ,  ^      •   ^    x-     i 

,  _ .  of  2,125  cases  of  typhoid  fever  164,  or  7.7  per  cent,  had  previously  been  treated  for  intestinal 
disorders. 


lisorclers. 

Of  2,125  cases  of  typhoid  fever  1,961,  or  93.3  per  cent,  had  not  been  treated  for  intestinal 
disorders. 


145 


Casefi  of  typhoid  fever  aviong  men  with  or  without  preceding  diarrheal  diseases  for 
seven  regiments  of  the  Third  Division,  Seventh  Army  Corps,  Jacksonville,  Fla. 


Mean  strength. 

Diarrheal  dis- 
eases. 

Cases  of  diar- 
rheal diseases 
followed  by  ty- 
phoid fever. 

Num- 
ber of 
men 
with- 
out 
diar- 
rheal 
dis- 
eases. 

Typhoid  fever 
without  preced- 
ing diarrheal 
disease. 

Total 

Regiments. 

Num- 
ber of 
cases. 

Num- 
ber of 
indi- 
vidu- 
als. 

Num- 
ber of 
cases. 

In  100 
men  with 
preced- 
ing diar- 
rhea. 

Num- 
ber of 
cases. 

In  100 
individu- 
als with- 
out pre- 
ceding 
diarrhea. 

of  ty- 
phoid 
i  ever. 

4th  Illinois -. 

1,194 
1,304 
1,217 
1,149 
1,262 
945 
919 

137 
145 
563 
69 
422 
.521 
513 

115 
133 
454 
67 
344 
365 
399 

0 
9 
11 
10 

0.0 
6.7 
2.4 
14.9 

1,079 
1,171 
763 
1,082 
918 
580 
520 

238 
125 
107 
276 
224 
77 
114 

22.0 
10. 6 
14.0 
25.9 
24.4 
13.2 
21.9 

238 

134 

2d    Mississippi 

6th  Missouri 

118 

286 

3d    Nebraska 

.56  1         16.2 

8  ,           2.1 

37  1           9.2 

280 

2d    South  Carolina  . .  - 
2d    Virginia  Cavalry. 

85 
151 

Total 

7,990 

2,370 

1,877 

131 

6.9 

6. 113 

1.161 

18.9 

1,293 

An  examination  of  these  tables  shows  that  those  men  who  had 
experienced  previous  diarrheal  attacks  were  much  less  liable  to  sub- 
sequent attacks  of  typhoid  fever  than  those  who  had  not  had  such 
intestinal  attacks. 

ORIGIN  AND   SPREAD    OF    TYPHOID    FEVER   IN   THE   SEVENTH 

ARMY  CORPS. 

This  did  not  differ  from  the  origin  and  propagation  of  typhoid  fever 
in  the  other  army  corps  of  which  we  have  already  treated,  and  hence 
we  shall  only  devote  a  few  words  to  this  subject.  In  referring  to  the 
progress  of  typhoid  fever  in  the  Second  Division,  which  was  the  first 
to  assemble  at  Jacksonville,  we  have  shown  that  the  disease  was 
imported  by  five  regiments  of  the  nine  originally  constituting  this 
division;  and,  further,  that  it  was  just  in  these  regiments  that  typhoid 
fever  most  rapidly  developed  during  June.  As  the  men  of  those  regi- 
ments not  importing  typhoid  fever  and  in  which  so  few  cases  devel- 
oped in  June  had  the  same  opportunity  for  infection  from  shallow 
wells  within  the  vicinity  of  the  camp,  we  must  conclude  that  the 
importation  of  cases  of  typhoid  fever  was  the  most  important  factor 
in  the  origin  of  this  disease  in  the  Second  Division.  We  have  also 
seen  that  all  of  the  regiments  of  the  First  Division  arriving  from 
Miami,  Fla.,  imported  the  disease  and  that  onlj^  one  of  the  eight  regi- 
ments of  the  Third  Division  failed  to  import  cases  of  tj^phoid  fever. 
The  sources  of  infection  were,  therefore,  plainly  internal  to  the  several 
camps,  whatever  chances  for  outside  infection  there  may  have  been. 

With  regard  to  the  latter,  we  call  attention  to  the  absence  of  typhoid 
fever  in  Jacksonville  during  the  year  1898,  and  we  give  herewith  a 
table  showing  the  slight  prevalence  of  typhoid  fever  and  other  fevers 
in  that  city  for  the  years  1895-1898,  inclusive;  so  that  we  must  con- 
clude that  although  there  may  have  been  individual  cases  of  infection 
outside  of  the  camp,  the  chief  source  of  the  disease  was  to  be  found 


7273- 


-10 


146 

witkin  the  camp.  As  regards  the  propagation  of  the  disease  iu  the 
several  organizations,  the  regimental  histories  and  graphic  charts 
should  be  consulted.  A  careful  examination  of  these  will  show  that 
typhoid  fever,  as  it  appeared  in  the  various  regiments  of  the  Seventh 
Army  Corps,  consisted  essentially  of  a  series  of  company  epidemics, 
wh@se  discrepancies,  both  in  the  time  of  beginning  as  well  as  in  their 
course  and  ending,  were  such  as  to  preclude  the  assumption  of  a  com- 
mon, simultaneous,  and  more  or  less  continuously  acting  agency  as  the 
chief  means  in  the  spread  of  the  disease.  Propagation  of  the  disease 
through  contamination  of  the  general  water  supply  can  be  safely 
exdluded. 


Mortality  table  of  Jacksonville,  Fla.,  relative  to  typhoid  fever  and  other  fevers 
which  may  be  mistaken  for  it,  from  1895  to  1898,  inclusive. 

[Deduced  from  statistics  by  health  oiflce  of  that  city.  ] 


Cause  of  death. 

1895. 

1896. 

1897. 

1898. 

Total. 

Average 
per  year. 

Popu- 
lation. 

33 
9 
9 

I 
5 
i 
1 
1 

8 
5 
7 
4 
3 
1 
1 
0 
0 

10 
6 
2 
0 
1 
0 
1 
0 
0 

5 
9 
3 
3 
1 
0 
0 
0 
0 

45 
29 
21 
9 
8 
6 
6 
1 
1 

30,000 
30,000 

Typhoid 

Malarial .- , 

30,000 

Typhomalarial    . .        . 

30,ono 

30,000 

Enteric -- 

30,000 

30,000 

30,000 

30,000 

57 

38 

20 

21 

126 

30,000 

Probable  typhoid  per  1,000 

1.90 

0.93 

0.66 

0.71 

1.05 

30.000 

N.  B.— During  the  four  years  3  deaths  from  brain  fever,  1  death  from  gastric  fever,  and  1 
death  from  septic  fever  were  also  recorded. 

We  have  already  shown  that  the  method  in  use  for  the  disposal  of 
excreta  differed  in  the  three  divisions  of  this  corps,  the  First  Division 
being  provided  with  flushing  troughs,  the  Second  Division  with  half 
ttfbs,  and  the  Third  Division  with  open  pits  dug  in  the  sandy  soil.  As 
these  divisions  were  otherwise  placed  under  similar  conditions  as  to 
c^mp  sites,  water  supply,  etc. ,  it  is  interesting  to  observe  that  while 
the  morbidity  from  typhoid  fever  in  the  First  Division  was  150.32  per 
1,000  of  mean  strength,  this  reached  161.70  per  1,000  for  the  Third  Divi- 
sion and  the  high  figure  of  250.30  per  1,000  for  the  Second  Division. 
It  should  also  be  noted  that  the  figures  given  for  the  Third  Division 
only  embrace  cases  of  recognized  typhoid  fever  and  do  not  include 
probable  cases,  such  as  prolonged  malarias,  incorrectly  so  diagnosed. 
Had  the  latter  been  included,  the  morbiditj^  per  1,000  would  have 
approximated  that  given  for  the  Second  Division.  Hence  we  see  that 
with  water  carriage  for  its  fecal  matter,  typhoid  fever  never  reached 
as  high  a  proportion  in  the  First  Division,  although  all  of  its  six  regi- 
ments arrived  in  Jacksonville  in  August,  1898,  thoroughly  infected 
with  this  disease,  the  result  of  a  previous  epidemic  at  Miami,  Fla. 
With  conditions  ripe  for  its  propagation,  the  epidemic  only  assumed 


147 

moderate  proportions  in  the  First  Division  as  compared  with  its  course 
in  the  Second  and  Third  divisions.  This  we  believe  was  largely  due 
to  the  prompt  removal  of  excreta  and  to  the  lessened  chance  for  fly 
infection  of  food  and  sink  infection  of  the  person  of  the  soldier, 
especially  his  clothing  and  shoes. 

Relative  to  the  spread  of  the  disease  from  personal  contact  in 
crowded  tents,  which  we  have  discussed  in  connection  with  certain 
regiments  of  the  Second  Corps  at  Camp  Meade,  Pa.,  we  have  only 
been  able  to  obtain  information  on  this  point  in  ten  companies  of  five 
different  regiments  in  the  Second  Division,  Seventh  Corps.  (For 
details  see  histories  of  these  regiments. )  These  squad  groups  of  the 
sick,  as  plotted  in  their  tents,  would  appear  to  suggest  a  mode  of 
disseminating  infection  which  more  effectively  reached  and  acted 
upon  certain  limited  groups  of  men  while  it  passed  by  others.  We 
believe  that  this  would  be  entirely  compatible  with  the  assumption 
of  a  dominating  tent,  squad,  or  comrade  infection.  These  observa- 
tions, taken  in  connection  with  our  studies  of  certain  regiments  in 
the  Second  Corps,  have  led  us  to  the  opinion  that  squad  or  comrade 
infection  was  a  very  important  factor  concerned  in  the  propagation 
of  typhoid  fever  in  the  Seventh  Army  Corps. 


CHAPTER  XIII. 
COINCIDENT  MALARIA  AND  TYPHOID  FEVER. 

Early  in  the  war  of  the  rebellion  army  medical  officers  reported  the 
prevalence  of  a  form  of  fever  among  the  soldiers  which  differed  in  some 
respects  from  typhoid  fever  as  observed  in  the  Northern  States.  In 
December,  1861,  a  board  of  medical  officers,  consisting  of  Surg.  A.  N. 
McLaren,  Brigade  Surg.  G.  H.  Lyman,  and  Asst.  Surg.  M.  J.  Asch, 
was  appointed  to  determine  "whether  it  (this  fever)  should  be  con- 
sidered an  intermittent  or  bilious-remittent  fever  in  its  inception, 
assuming  in  its  course  a  typhoidal  type  or  a  typhoid  fever  primarily." 
The  members  of  this  board  visited  and  inspected  certain  camps  and 
hospitals  and  obtained  information  concerning  others  by  correspond- 
ence with  medical  officers.  They  came  to  the  conclusion  that  the 
large  majority  of  the  febrile  cases  then  occurring  among  the  troops 
were  "  bilious-remittent  fevers,  which,  not  having  been  controlled  in 
their  primary  stage,  have  assumed  that  adynamic  type  which  is  pres- 
ent in  enteric  fever." 

In  1862  a  board  of  medical  officers  was  convened  for  the  purpose  of 
revising  the  form  of  sick  report  then  in  use  in  the  Army.  One  mem- 
ber of  this  board  was  Surg.  J.  J.  Woodward.  Major  Woodward  had 
spent  the  greater  part  of  the  preceding  year  with  the  Ar^ny  of  the 
Potomac  and  was  familiar  with  the  form  of  fever  upon  which  the 
previously  appointed  board  had  reported.     However,  his  opinion  of 


148 

the  nature  of  this  fever  was  never  iu  accord  with  the  report  made  by 
the  board  of  inspection.  As  has  already  been  stated,  this  board  came 
to  the  conclusion  that  the  fever  about  which  so  much  had  been  said 
was  a  bilious-remittent  fever  which  had  assumed  that  adynamic  type 
present  in  enteric  fever;  in  other  words,  this  board  defined  the  fever 
as  a  malarial  fever  with  typhoid  symptoms.  On  the  other  hand  Major 
Woodward  believed  that  "the  prevailing  fevers  of  the  Army  of  the 
Potomac  were  hybrid  forms,  resulting  from  the  combined  influence  of 
malarial  poisoning  and  of  the  causes  of  typhoid  fever."  In  accord- 
ance with  the  opinion  of  Surgeon  "Woodward,  the  board  appointed  to 
revise  the  form  of  sick  report  then  in  use  in  the  Army  suggested  to 
the  Surgeon-General  that  this  fever  be  known  as  typho-malarial  fever. 

It  should  be  clearly  seen  that  there  were  among  the  medical  officers 
during  the  war  of  the  rebellion  two  very  distinct  ideas  concerning  the 
nature  of  the  disease  which  they  reported  under  the  name  of  typho- 
malarial  fever.  The  idea  expressed  by  the  board  of  investigation, 
that  this  was  a  severe  form  of  malarial  fever,  was  the  most  widely 
accepted,  and,  while  the  name  proposed  by  Major  Woodward  was 
adopted,  the  opinion  of  the  first  board  concerning  the  nature  of  the 
disease  was  the  one  generally  accepted .  Thus  it  happened  that  the  dis- 
ease was  designated  as  proposed  by  Woodward,  but  was  defined 
according  to  the  opinion  of  the  board  of  inspection.  Ever  since  the 
first  use  of  the  name  typho-malarial  fever,  the  majority  of  physicians 
in  the  United  States  using  this  name  would  have  defined  it  as  a  severe 
form  of  malarial  fever.  However,  this  was  never  the  opinion  of 
Major  Woodward. 

In  a  scholarly  paper,  read  before  the  International  Medical  Con- 
gress held  at  Philadelphia  in  1876,  Major  Woodward  discussed  what 
we  would  now  call  mixed  malarial  infections.  He  endeavored  to  show 
that  malarial  infection  might  modify  both  tj^phus  and  typhoid  fevers. 
It  must  be  admitted  that  in  this  paper  he  brought  forward  some  very 
interesting  and  convincing  historical  evidence  of  the  prevalence  of 
such  mixed  infection  in  armies.     He  states: 

Is  it  wonderful,  then,  that  hybrid  forms  of  disease,  exhibiting  the  ordinary 
symptoms  of  malarial  and  of  typhoid  fever,  variously  combined,  should  long  have 
been  observed  in  this  country?  In  fact,  such  hybrid  forms  have  long  been  observed 
in  Europe  also.  In  the  first  volume  of  iiis  Institutes,  published  in  1781,  Burserius 
recognized  them  as  a  group,  ''tlie  Porportionata,"  which  he  defines  as  the  com- 
pound species  composed  of  thesynochus  (an  old  name  for  typhoid  fever  j  and  inter- 
mittent fever.  This  union,  he  says,  occurs  especially  "when  intermittent  fevers 
prevail  epidemically,  or  at  least  constitute  the  prevailing  and  stationary  disease; 
for  then  almost  all  diseases  bearing  some  resemblance  to  intermittents,  or  sporadic 
or  intercurrent  fevers,  of  v^hatever  other  kind,  are  combined  with  the  intermitting 
fevers."  Herman  Schmidt,  in  his  account  of  the  so-called  summer  fever,  which 
was  epidemic  throughout  Europe  during  the  year  1827,  has  still  more  elaborately 
described  as  the  form  of  fever  then  most  generally  prevailing  a  combination  of 
intermittent  fever  with  the  endemic  typhus  of  Europe  (our  typhoid  fever).  He 
had  subdivided  the  resulting  hybrid  forms  into  two  chief  classes:  (1)  Typhus  inter- 


149 

mittens  subintrans.  which  he  defines  as  a  combination  of  typhus  (our  typhoid)  and 
intermittent  fever,  with  a  preponderance  of  the  typhus  element.  (3)  Febris  inter- 
mittens typhosa,  which  he  defined  as  a  similar  combination,  with  a  preponderance 
of  intermittent  fever,  I  would  refer  you  to  his  elaborate  treatise  for  many  sugges- 
tive details.  Naumann  has  quoted,  with  approval,  the  views  of  Burserius  and 
Schmidt,  and  mentions  corroborative  observations  by  several  other  writers,  to 
which  I  might  add  many  more  did  the  scope  of  this  discourse  permit. 

Woodward  also  refers  to  the  studies  of  the  Walcheren  fever  that 
prevailed  among  the  English  army  invading  Holland  in  1809,  as 
reported  by  Dawson  and  Davis. 

In  the  paper  referred  to  "Woodward  states : 

I  never  meant  this  term  (typho-malaria)  to  represent  a  specific  type  of  fever, 
but  intended  it  to  designate  all  the  many-faced  brood  of  hybrid  forms  resulting 
from  the  combined  influence  of  the  causes  of  malarial  fever  and  of  enteric  fever. 

In  another  place  he  states : 

And  this  brings  me,  at  length,  to  answer  the  question.  Is  typho-malarial  fever 
a  special  type  of  fever?  and  I  reply  unhesitatingly  that  it  is  not.  I,  at  least,  am 
free  from  the  blame  of  that  error,  if  anyone  has  fallen  into  it.  In  my  first  pub- 
lished account  of  typho-malarial  fever  I  expressly  denied  that  it  could  be  regarded 
as  a  new  disease.  "Much  rather,"  I  said,  "should  it  be  considered  simply  as  a 
new  hybrid  of  old  and  well-known  pathological  conditions,  in  which  the  exact 
train  of  symptoms  is  as  variable  as  the  degree  of  preponderance  attained  by  each 
of  the  several  concurring  elements."'  And  this  is  the  view  which  I  advocate 
to-day.  The  essential  point  which  I  desire  most  to  impress  upon  you  is  the  recog- 
nition of  the  group  of  hybrids  between  typhoid  fever  and  malarial  fevers. 

Furthermore,  Woodward  advocated  the  idea  that  typho-malarial 
fever  was  modified  in  individuals  suffering  under  the  scorbutic  taint. 
He  says: 

Now,  when  either  of  the  forms  of  typho-malarial  fever  which  I  have  described 
occurred  in  individuals  suffering  under  the  scorbutic  taint  the  symptoms  were 
modified  to  a  degree  corresponding  to  the  intensity  of  the  scorbutic  condition. 
The  effect  of  the  complication  was  to  increase  the  tendency  to  mental  and  bodily 
prostration  during  the  disease,  to  tardy  convalescence  subsequently,  and  to 
increase  the  frequency  of  petechial  and  purpuric  eruptions  and  of  hemorrhages 
from  the  nose  and  bowels.  Sometimes  the  characteristic  scorbutic  condition  of 
the  mouth  was  developed  daring  the  progress  of  the  fever  when  it  had  not  pre- 
viously made  its  appearance.  When  the  characteristic  typhoid  process  was  devel- 
ojjed  in  individuals  laboring  under  a  marked  scorbutic  taint,  the  symiitoms  closely 
resembled  those  of  spotted  typhus.  Fatal  hemorrhages  from  the  bowels  were 
common  in  such  cases,  and  on  dissection  the  lower  patches  of  Pe.yer  were  found 
converted  into  dark  red  or  black  pultaceous  sloughs  of  considerable  size  and  thick- 
ness. I  suppose  the  scorbutic  condition  to  have  modified  the  typhoid  ulceration 
in  such  cases  just  as  we  often  see  it  modify  the  condition  of  superficial  ulcerations 
or  of  gunshot  wounds. 

Major  Woodward  closes  the  j)aper  above  referred  to  with  the  fol- 
lowing statement: 

If  I  have  rightly  presented  the  subject,  a  just  appreciation  of  the  hybrid  forms 
which  I  have  urged  on  your  attention  to-day  is  a  matter  of  grave  practical  impor- 
tance, not  merely  as  a  question  of  militar}-  medicine,  though  most  important  in 
that  connection,  for  I  take  it  that  whenever  again  hereafter  an  army,  recruited  in 


150 

a  comparatively  nomnalarial  region,  shall  campaign  on  malarial  soil,  these  hybrid 
forms  will  appear  once  more  in  epidemic  proportions;  but  meanwhile,  I  suppose, 
in  sporadic  or  endemic  wise,  we  shall  continue  to  have  these  cases  to  deal  with  in 
civil  practice  in  all  the  miasmatic  regions  of  our  Middle  and  Southern  States,  and 
their  ready  comprehension  is  therefore  a  question  of  serious  moment  to  every 
American  physician  engaged  in  practice  in  such  localities. 

Adopting  the  nomenclature  suggested  by  Woodward,  there  were 
reported  to  the  Surgeon-General's  Office,  beginning  with  July  1,  1862, 
and  ending  June  30,  1866,  57,400  cases  of  typho-malarial  fever,  with 
5,360  deaths. 

Since  the  war  of  the  rebellion  the  physicians  of  this  country  have 
been  divided  in  their  opinions  concerning  the  so-called  typho-mala- 
rial fever.  A  considerable  number  of  those  practicing  in  the  South- 
ern States  have  continued  to  use  this  term,  but  the  majority  of  these 
have  used  this  designation  to  represent  what  they  believe  to  be  a 
severe  form  of  malarial  fever,  and  have  never  placed  Woodward's 
interpretation  upon  the  nature  of  the  disease.  On  the  other  hand,  a 
large  proportion  of  the  physicians  practicing  in  the  Northern  States 
have  denied  the  existence  of  this  hybrid  infection.  It  is  quite  evident 
that  the  ultimate  solution  of  this  problem  had  to  wait  upon  the  dis- 
covery of  the  Plasmodium  of  malarial  fever  by  Laveran  and  of  the 
bacillus  of  typhoid  fever  by  Eberth. 

Laveran  ^  appears  to  have  been  the  first  to  record  cases  of  so-called 
mixed  malarial  and  typhoid  infection.  In  1884  he  reported  a  case  of 
intermittent  fever  occurring  during  convalescence  from  typhoid  fever, 
and  a  second  case  in  which  the  malarial  attack  immediately  preceded 
and  closely  followed  the  attack  of  typhoid  fever.  These  cases  are  as 
follows : 

Case  1. — Soldier;  age  22;  admitted  to  military  hospital  at  Constantine,  Algeria, 
August  2,  1882.  In  March,  1881,  he  was  said  to  have  had  a  fever  which  lasted 
three  days,  with  herpes  labialis.     He  recovered  without  quinine. 

July  31. — The  first  symptoms  of  his  disease  were  malaise,  headache,  thirst,  high 
fever  without  chill,  and  general  weakness;  fever  continued  without  marked 
remission  until  entrance  to  hospital;  temperature,  40.8  °  a.  m.,  40  °  p.  m.  Typhoid 
condition  well  marked,  slight  diarrhea,  pain  upon  pressure  in  the  right  iliac 
fossa.  Although  the  diagnosis  of  typhoid  fever  appeared  probable,  quinine  was 
prescribed  for  a  few  days. 

The  diagnosis  of  typhoid  fever  was  later  fully  confirmed,  although  rose  spots 
were  not  present. 

August  11. — Defervescence  beginning. 

20th. — Temperature  normal;  the  chart  is  typical  of  typhoid  fever. 

29th. — The  patient  reported  that  he  had  a  chill  for  several  days  at  about  7  p.  m.; 
temperature  39.5'  p.  m. 

30th. — Temperature  37.2°  a.m.,  38.5°  p.  m.  Examination  of  the  blood  made  at 
8  a.  m.  shows  a  large  number  of  pigmented  malarial  parasites,  both  free  and  intra- 
corpuscular;  quinine  was  given. 

31st. — Apyrexia;  parasites  in  the  blood  reduced  in  numbers;  quinine  continued. 

September  3. — No  parasites  found.     Recovery  followed. 

^  Laveran:  Traite  des  Fievres  Palustres,  Paris,  1884. 


151 

Case  2. — Soldier:  age,  23;  admitted  to  hospital  January  25.  1883.  Previous 
history  of  interiuittent  fever  in  August,  1882.  Present  sickness  beginning  on 
January  20;  characterized  by  daily  chills  at  2  a.  m. 

January  24. — Temperature  40.2°  a.  m.,  38.9°  p.  m.  Anaemia  well  marked; 
mucous  membranes  pale;  general  emaciation  and  weakness;  anorexia.  Examina- 
tion of  the  blood  at  2.30  p.  m.  shows  pigmented  malarial  parasites,  free  and  within 
the  blood  corpuscles;  also  pigmented  leucocytes:  quinine  given. 

25th. — Temperature  38.2°  a.m., 38.4°  p.m.;  quinine. 

Under  this  treatment  the  parasites  disappeared,  temperature  returned  t©  nor- 
mal, and  appetite  increased. 

February  8. — Patient  complains  of  inability  to  sleep;  headache,  and  general 
malaise  for  two  or  three  days.  There  has  been  no  chill.  Temperature  39.5°  a.  m., 
40.6°  p.  m.  Examination  of  the  blood  failed  to  show  malarial  parasites.  Quinine 
given. 

9th. — Fever  continues.  Temperature,  39.7°  a.  m.,  39.9°  p.  m.;  prostration  well 
marked;  general  malaise,  headache,  insomnia,  slight  diarrhea,  and  some  pain  on 
pressure  in  the  right  iliac  fossa;  quinine  continued. 

11th. — Temperature  39.3°  a.  m.,40.3°  p.m.;  rose  spots  appeared  on  the  abdemen; 
quinine  discontinued. 

15th. — Defervescence  beginning. 

20th. — Temperature  normal  on  the  seventeenth  day  of  the  disease. 

28th. — Patient  aniemic  and  weak.  Examination  of  the  blood  shows  no  malarial 
parasites.  Condition  continued  to  improve  until  March  8,  when  a  chill  occurred 
at  midday  followed  by  fever;  temperature  rising  to  40.3°.  Examination  of  the 
blood  showed  malarial  parasites  of  the  tertian  variety;  quinine  given.  From  this 
time  under  the  use  of  quinine  convalescence  was  rapid. 

In  this  country,  Kinyoun/in  a  study  of  malarial  and  typhoid  fevers 
in  the  United  States  Marine  Hospital,  New  York,  recorded  under  the 
title  of  " entero-malarial  fever"  cases  showing,  "a  combination  of 
malarial  and  enteric  fevers,  which  clinically  presented  some  devia- 
tions from  the  general  course  of  either  disease." 

He  divided  his  cases  into  two  groups: 

I.  Cases  in  which  the  symptoms  of  malarial  fever  predominate, 
masking  the  enteric  lesion;  2  cases. 

II.  Cases  in  which  the  symptoms  of  enteric  fever  are  most  promi- 
nent; 3  cases. 

The  following  is  the  history  of  the  cases  belonging  to  the  first  group: 

Case  1. — Patient  taken  sick  two  days  before  admission,  the  attack  commencing 
with  a  chill  followed  by  fever,  marked  by  a  remission.  A  microscopical  examina- 
tion of  the  blood  was  made  and  "  a  large  number  of  the  plasmoclia  malarice  was 
found  free  both  in  the  serum  and  within  the  blood  corpuscles.  This  established 
the  diagnosis  of  raalarial  fever  of  the  remittent  type. "  On  the  fifth  day  after 
admission  there  appeared  on  his  abdomen  several  suspicious-looking  spots  sug- 
gestive of  enteric  complications.  On  the  day  following  he  had  slight  epistaxis,  a 
tendency  to  diarrhea  and  tenderness  in  the  right  iliac  fossa.  The  case  afterwards 
ran  the  typical  course  of  typhoid  fever.    Patient  recovered. 

Case  2, — The  symptoms  were  less  pronounced  than  in  the  first  case.  "The 
Plasmodium  malarice  was  found  in  the  blood  in  abundance,  and  later  the  typhoid 
bacillus  was  isolated  from  the  stools." 


'  Weekly  Abstract  of  Sanitary  Reports,  Vol.  V,  1890. 


152 

Concerning  the  3  cases  of  Group  II,  the  author  says:  "The  enteric 
symptoms  were  well  marked,  giving  a  clear  history  of  the  disease." 
There  were  lassitude,  etc.,  "followed  by  diarrhea,  epistaxis,  and 
t3rmpanites,  and  in  one  case  slight  hemorrhage."  In  these  cases  the 
parasite  was  found  "confined  to  the  corpuscle,  not  free  in  the  blood." 

In  one  of  these  cases,  during  the  third  week  when  convalescence 
appeared  to  have  been  established  and  temperature  was  normal,  he 
had  a  sudden  access  of  fever  two  days  in  succession.  Examination 
showed  the  plasmodiimi  malarice.     Patient  recovered. 

The  other  cases  of  this  group  died,  1  from  peritonitis  and  1  from 
]3neumonia. 

Kinyoun  does  not  record  the  variety  of  the  parasite  found  in  his 
cases. 

In  1894,  W.  Gilman  Thompson,  in  a  paper  before  the  Association 
of  American  Physicians,  reported  3  cases  of  mixed  malarial  and 
tjT^hoid  infection.  The  following  is  taken  from  Thompson's  histor}' 
of  one  of  his  cases: 

On  his  admission  his  appearance  suggested  typhoid  fever,  and  he  was  treated 
accordingly  by  the  Brand  method  of  cold  tub-bathing.  There  was  slight  enlarge- 
ment of  the  splenic  area  of  dullness,  great  prostration,  diarrhea,  and  a  typical 
typhoid  tongue,  dry,  coated  on  the  dorsum,  with  thin  red  margins  and  swollen 
papillee.  There  was  continued  fever,  which  lasted  for  seven  weeks,  and  during 
this  period  the  patient  developed  the  following  symptoms:  A  genuine  typhoid 
eruption,  there  being  some  forty  distinct  rose  spots  on  the  abdomen  and  chest, 
which  appeared  in  successive  gi'oups:  hemorrhages  from  the  bowels,  of  which 
there  were  four  or  five  of  considerable  amount;  tympanites,  bronchial  catarrh, 
slight  albuminuria  with  granular  casts,  semistupor  and  delirium,  subsultus,  great 
prostration  and  emaciation,  and  the  facies  of  the  typhoid  condition. 

On  the  thirteenth  day  of  the  illness  there  was  a  severe  chill,  lasting  about  three- 
quarters  of  an  hour,  and  so  violent  that  the  patient  shook  the  bed.  It  was  accom- 
panied by  a  rise  of  temperature  to  106.6°  F.,  but  there  was  no  sweating.  During 
the  third  week  two  other  chills  occurred  of  equal  violence.  As  the  first  took 
place  before  the  hemorrhage,  and  also  before  the  eruption  became  decisive,  and 
as  there  was  nowhere  evidence  of  suppuration,  it  appeared  possible  that  there 
might  be  error  in  the  diagnosis,  and  the  blood  was  carefully  examined  for  the  mala- 
rial Plasmodium.  It  was  found  in  exceptionallj^  large  ni-mbers  in  the  red  cor- 
puscles and  a.so  independent  of  them.  When  the  next  chill  and  exacerbation  of 
temperature  occurred  quinine  was  given  hypodermically.  with  the  effect  of  reduc- 
ing the  temperature  4.5""  (105.5  to  101"  F.).  This  treatment  was  several  times 
repeated,  and  on  one  occasion  at  the  end  of  the  third  week  the  temperature  was 
temporarily  reduced  from  106.4°  to  99°  F,  No  more  chills  occurred  after  the 
beginning  of  the  fourth  week,  but  the  use  of  quinine  was  continued  by  the  mouth, 
and  the  bathing,  previously  interrupted  by  the  hemorrhages,  resumed.  The 
patient  made  a  good  recovery,  and  after  fifty- five  days  in  the  hospital  was  dis- 
charged, cured. 

With  reference  to  these  cases  Thompson  saj^s: 

In  the  first  case  reported  the  Plasmodium  became  active  during  the  height  of  the 
typhoid  disease.  In  the  second  and  third  cases  the  malarial  symptoms  remained 
latent  (although  the  Plasmodium  must  have  been  already  present)  until  the  force 
of  the  enteric  infection  had  been  completely  expended,  when  they  assailed  a  body 
weakened  by  a  fever  of  considerable  duration. 


153 

Thompson  believes  that  while  it  is  unwise  to  accept  the  term  typho- 
malarial  fever  as  indicating  a  third  form  of  disease,  it  can  not  be  denied 
that  the  two  diseases  may  coexist. 

Osier ^  reports  3  cases  in  which  "there  was  a  definite  history  of 
malaria  within  a  few  months  of  the  onset  of  the  typhoid  fever,"  and 
1  case  in  which  a  patient  having  malaria  subsequently  developed 
typhoid  fever.     The  history  of  the  latter  case  is  as  follows : 

The  patient,  a  man  aged  20,  had,  during  sixteen  days  prior  to  admission,  head- 
ache and  cough,  occasional  nose-bleeding,  and  three  chills.  On  admission,  October 
16,  the  temperature  was  100%  but  fell  in  the  early  morning  of  the  17th  to  96". 
The  malarial  parasites  were  found  to  be  present  in  the  blood.  He  was  ordered 
quinine,  4  grains,  three  times  a  day.  On  the  17th  the  temperature  began  to 
rise  a  little  after  12  a.  m.,  and  at  3.30  p,  m.  he  had  a  chill,  after  which  the  tem- 
perature rose  to  nearly  105' ,  then  fell  throughout  the  next  night  and  was  normal 
at  8  a.  m.  The  case  was  one  of  ordinary  tertian  intermittent,  and  the  quinine  was 
continiTed.  On  the  18th,  19th,  20th,  21st,  and  22d  the  temperature  was  normal  or 
subnormal.  A  two-hourly  temperature  had  been  taken.  Up  to  8  a.  m.  of  the  22d 
he  had  taken  80  grains  of  quinine.  He  had  no  more  fever,  and  the  malarial  para- 
sites had  disappeared  from  the  blood.  At  8  a.  m.  on  the  22d  the  temperature  was 
97.5°.  At  4  p.  m.  it  was  98".  It  gradually  rose  through  the  evening,  and  at  12 
midnight  it  was  102.5  .  The  next  morning  it  was  102.2%  rose  throughout  the  day, 
and  from  4  to  8  p.  m.  was  at  105%  so  that  within  the  twenty- four  hours  from  4 
p.  m.  on  the  22d  to  4  p.  m.  on  the  23d  the  temperature  had  risen  7%  Naturally 
we  thought  this  was  a  recurrence  of  malaria,  in  spite  of  the  administration  of 
quinine,  of  which  he  had  had  96  grains  up  to  10  a.  m.  on  the  23d.  From  8  p.  m. 
on  the  23d  throughout  the  24th  and  25th,  the  temperature  remained  practically 
between  103"  and  105%  uninfluenced  by  the  quinine  (which  was  continued)  and 
only  influenced  slightly  by  sponging.  The  quinine  was  continued  until  noon 
on  the  26th.  The  whole  appearance  of  the  man  was  suggestive  of  typhoid  fever, 
and  subsequently  spots  appeared,  the  spleen  enlarged,  and  the  disease  ran  a  per- 
fectly normal  course,  typical,  but  of  great  severity,  the  temperature  not  falling  to 
normal  until  between  the  fifth  and  sixth  weeks. 

Osier  further  says: 

There  was  no  case  with  the  character  of  the  two  diseases  so  blended  tnat  it 
seemed  a  compound  or  hybrid  malady,  nor  was  there  an  instance  in  which  the 
manifestations  of  the  two  diseases  were  concurrent. 

The  same  author^  records  a  case  of  continued  malarial  fever,  last- 
ing from  September  28  to  October  7,  1894,  in  whose  blood  the  sestivo- 
autumnal  parasite  was  found  during  the  attack,  and  which  was  fol- 
lowed by  a  severe  typhoid  fever  beginning  on  November  6,  or  thirty 
days  later.     The  case  ended  in  recovery. 

Vincent,^  a  French  army  surgeon,  on  duty  at  the  bacteriological 
laboratory  of  the  Hospital  du  Dey  in  Algeria,  records  17  cases  of  mixed 
malarial  and  typhoid  infection,  which  he  designates  as  ^'fievre  fypho- 
palustre.''^ 

These  cases  were  observed  among  soldiers  who  had  served  in  Mada- 


^  Johns  Hopkins  Hospital  Reports,  Vol.  IV,  1895. 
^  Johns  Hopkins  Hospital  Reports,  Vol.  V,  1895. 
''Mercredi  Medical,  Paris,  1895,  pp.  572-579. 


154 

gascar  and  Algeria.  Although,  the  clinical  picture  was  a  variable  one, 
sometimes  partaking  of  that  of  malaria  and  sometimes  of  that  of 
typhoid  fever,  as  a  rule  the  typhoid  symptoms  were  dominant.  The 
earliest  symptoms  were  manifested  by  a  rise  of  temperature,  with  or 
without  chill,  severe  headache,  sometimes  epistaxis,  and  general  body 
pains.  Once  established,  the  fever  continued,  often  irregular  in  its 
course,  or  higher  in  the  morning  than  in  the  evening.  In  2  cases  the 
initial  fever  was  of  short  duration  and  was  followed  by  an  almost 
normal  temperature,  the  latter  interrupted  by  an  occasional  rise.  The 
pulse  followed  the  oscillations  of  temperature,  remaining  in  the  mean- 
while frequent.  It  often  varied  from  130  to  150  or  more  to  the  minute. 
It  was  dicrotic,  compressible,  sometimes  threadlike,  and  was  accom- 
panied by  cardiac  distress  and  irregularity. 

Profound  stupor,  delirium,  great  excitement  alternating  with  col- 
lapse, earthy  hue  of  countenance,  dusky,  dry  lips  and  tongue,  and 
marked  albuminuria,  symptoms  which  indicated  the  severity  of  the 
infection,  were  to  be  seen  in  all  of  these  cases.  Sometimes  the  disease 
was  ushered  in  by  coma  like  that  of  pernicious  malaria,  death  occur- 
ring during  the  first  week.  Thoracic  complications  (bronchitis  and 
pneumonia)  were  almost  constant.  Rose  spots  were  present  in  12 
cases.  Iliac  tenderness  was  present;  in  some  cases  constipation. 
Diarrhea,  slight  or  profuse,  was  the  rule.  One  patient  died  with  chol- 
eriform  symptoms.  Two  cardinal  sj^mptoms  were  never  lacking — the 
earthy  color  of  the  face  and  the  marked  enlargement  of  the  spleen. 
There  were  also  enlargement  and  tenderness  of  the  liver. 

While  death  might  be  caused  by  the  intensity  of  the  infection,  it 
was  often  in  consequence  of  complications  such  as  myocarditis,  paren- 
chymatous nephritis,  gangrene  of  the  lung,  lobular  pneumonia,  abscess 
of  the  kidney  and  spleen,  peritonitis,  etc. 

Convalescence  was  slow  and  was  sometimes  marked  by  isolated 
paroxysms. 

In  all  of  these  patients  microscopic  examination  of  the  blood  made 
during  life  and  at  the  beginning  of  the  disease  showed,  in  variable 
numbers,  the  malarial  parasite  (amoebic,  segmenting  forms,  and  cres- 
cents) except  in  1  case,  in  which  large  doses  of  quinine  had  been 
taken.  In  this  case  large  numbers  of  the  parasite  were  found  in  the 
tissues  of  the  spleen  after  death. 

Death  occurred  in  8  of  these  cases.  Swelling  or  ulcerations  of  Peyer's 
patches  were  found  in  all  in  varying  degree.  These  changes  were  often 
slight.  Once  or  twice  they  were  reduced  to  a  simple  psorentery  (sim- 
ple psorenterie).  The  mesenteric  glands  were  enlarged.  The  spleen 
constantly  increased  in  size,  weighing  in  one  case  700  grams  and  in 
another  900  grams,  and  its  surface  was  of  a  dark  color.  The  liver  was 
enlarged,  of  a  brown  color  and  soft  consistency.  The  kidneys  showed 
the  lesions  of  parenchymatous  nephritis.  Sections  of  the  liver  showed 
marked  pigmented  infiltrations  of  the  capillaries.     The  same  pigmen- 


155 

tation,  yellow  or  black,  was  found  iu  tlie  spleen.  Sections  of  the 
spleen  showed  sometimes  a  large  number  of  malarial  parasites  and 
crescents. 

In  all  of  the  fatal  cases  cultures  from  the  spleen  gave  a  motile 
bacillus,  which  did  not  liquefy  gelatine,  and  which  grew  upon  potato 
as  a  moist,  colorless  layer.  This  bacillus  grew  well  in  bouillon  to 
which  carbolic  acid  had  been  added,  and  did  not  ferment  lactose. 
It  showed  all  of  the  characteristics  of  the  bacillus  of  Eberth. 

As  the  result  of  the  microscopic  study  of  the  blood,  and  of  the 
pathological  and  bacteriological  findings  at  the  autopsy,  Vincent  con- 
cludes that  the  disease  under  consideration  is  ' '  none  other  than  a 
mixed  infection  due  to  the  association  of  the  typhoid  bacillus  and  the 
malarial  parasite.  Whether  the  typhoid  germ  developed  secondarily 
upon  a  soil  already  invaded  by  the  malarial  poison  (which  appears  to 
be  most  frequently  the  case),  or  whether  the  two  infections  are  coin- 
cident, they  produce  by  their  conjunction  a  remarkable  disease,  of 
hybrid  character,  sometimes  partaking  of  the  nature  of  remittent 
malarial  fever  and  sometimes  of  that  of  typhoid  fever. " 

In  1897  Da  Costa ^  reported  1  case: 

Male;  age,  25  years;  admitted  to  hospital  November  9.  Began  more  than  three 
weeks  ago  to  have  chills  every  second  day,  followed  by  high  fever  and  sweating. 
Has  had  some  diarrhea  for  two  weeks.  Upon  admission  he  had  continued  fever 
and  exhibited  features  of  typhoid  fever.     Temperature  rose  to  102.4°  in  the  evening. 

10th. — Temperature,  a.  m. ,  100° ;  p.  m., 103.8°.  Thereafter  the  fever  followed  the 
course  of  typhoid.     There  were  rose  spots  and  pea-soup  evacuations. 

Examination  of  the  blood  (date  not  stated)  "  showed  various  forms  of  malarial 
organisms,  though  not  the  crescentic  forms." 

Lyon'^  reported  the  following  observation : 

Case. — Male;  age,  48;  admitted  to  Johns  Hopkins  Hospital  January  5,  1898. 
Well-established  history  of  previous  malarial  attacks  during  June,  August,  and 
October,  1897.  Present  illness  dates  from  December  18.  Between  this  and  Janu- 
ary 5,  1898,  he  had  daily  chills,  slight,  and  confined  to  his  back.  No  sweats,  cough, 
or  epistaxis.  On  admission,  temperature,  respiration,  and  pulse  normal;  tongue 
dry  and  coated;  abdomen  full  and  rather  tense,  but  not  tender;  no  gurgling  in 
iliac  fossae;  a  few  rose  spots  on  abdomen;  bowels  constipated;  Ehrlich's  diazo- 
reaction  in  the  urine;  no  malarial  organisms  in  the  blood;  Widals  reaction  absent. 
During  the  forty-eight  hours  following  admission  two  suspicious  febrile  paroxysms 
occurred,  without  chills  or  sweating.  Repeated  examinations  of  the  blood  for 
malarial  parasites  were  negative.  The  case  pursued  the  characteristic  course  of 
typhoid  fever,  and  was  of  average  severity.  Widal  positive.  Temperature  reached 
normal  on  the  thirty-first  day.  Nine  days  later  there  was  a  febrile  paroxysm,  vrith- 
out  chill  or  sweating.  This  was  followed  by  a  similar  paroxysm  two  days  later, 
and  a  third  paroxysm  two  days  after  this.  Examination  of  the  blood  during  the 
third  paroxysm  show^ed  numerous  full-grown  pigmented  tertian  malarial  organ- 
isms and  a  few  young  hyaline  forms  in  the  red-blood  corpuscles.  Quinine  was 
given  in  full  doses,  and  no  further  evidence  of  malarial  fever  was  seen.  The  case 
ended  in  recovery. 

'  International  Clinics,  Vol.  II.  Seventh  Series,  July,  1897. 
-American  Journal  of  the  Medical  Sciences,  January,  1899. 


156 

It  will  now  be  interesting  to  inquire  whether  or  not  the  conditions 
prevalent  among  our  troops  during  the  late  war  with  Spain  have 
thrown  any  light  upon  the  so-called  typhomalarial  fever  as  defined 
by  Woodward.  Let  us  repeat  that  Woodward  believed  that  this  dis- 
ease was  due  to  the  coexistence  of  the  malarial  and  typhoid  poisons 
in  an  individual.  He  never  taught  that  typhomalarial  fever  was  only 
a  severe  form  of  malarial  infection. 

We  will  first  record  the  results  obtained  by  those  medical  officers 
who  were  assigned  to  general  hospitals  or  to  military  camps  for  the 
purpose  of  making  expert  blood  examinations. 

Acting  Asst.  Surg.  J.  J.  Curry,  U.  S.  Army,  on  duty  at  the  general 
hospital.  Fort  Myer,  Va.,  to  which  hospital  many  cases  were  sent 
from  Cami3  Alger,  Ya. ;  Jacksonville,  Fla. ;  and  Montauk  Point,  N.  T., 
reports  as  follows: 

We  have  met  in  ovir  investigation  12  cases  in  which  both  the  malarial  parasites 
were  found  in  the  blood,  and  at  the  same  time  the  Widal  reaction  was  obtained. 
In  but  1  of  these  cases  was  the  malarial  parasite  found  in  the  course  of  the  fever 
of  typhoid.  This  case  is  of  unusual  interest,  and  I  will  refer  to  it  later.  In  8  of 
the  cases  the  malarial  parasite  appeared,  with  accompanying  symptoms,  during 
the  convalescence.  In  the  remaining  3  cases  the  soldiers  had  had  typhoid  fever 
from  two  to  six  months  previously  to  the  malarial  attack.  At  the  time  the  biood 
of  these  cases  showed  the  malarial  parasite  it  also  gave  the  Widal.  These  cases, 
of  course,  do  not  come  under  the  head  of  mixed  infections,  but  their  mention 
serves  to  illustrate  a  possible  source  of  error  in  cases  reported  as  mixed  infections, 
simply  because  the  Widal  was  obtained  at  the  same  time  that  the  malarial  para- 
site was  found  in  the  blood.  In  8  of  these  cases  of  mixed  infection  the  mala- 
rial parasites  occurred  during  convalescence  only.  In  the  other  case  the  parasite 
was  found  both  in  the  first  week  of  the  disease  and  on  the  eighteenth  day  of  nor- 
mal temperature  during  convalescence.  All  of  these  men  came  from  Cuba  and. 
had  had  ma'!aria  there.  The  earliest  period  at  which  the  malarial  attack  occurred 
during  convalescence  was  on  the  fourteenth  day  of  normal  temperature;  1  case 
on  the  seventeenth,  1  on  the  eighteenth  day,  1  on  the  twenty-second  day,  and  the 
others  at  varying  intervals  from  one  to  two  months  after  the  temperature  had 
reached  normal. 

The  case  in  which  the  parasite  occurred  during  the  acute  stage  of  his  typhoid 
deserves  special  mention.  This  soldier,  a  man  about  27  years  of  age,  native  of 
Massachusetts,  a  first-class  private.  Signal  Corps,  U.  S.  Army,  was  in  Cuba  with 
the  Fifth  Corps  during  the  Santiago  campaign. 

History. — He  had  chills  and  fever  at  Santiago  July  and  August,  1898;  came  to 
Montauk  Point,  and  then  to  the  command  at  Fort  Myer  about  November  1.  On 
November  IT  he  had  a  chill  and  sharp  rise  of  temperature;  blood  examination 
showed  double  tertian  (2  crops  of  tertian  malarial  parasites,  1  mature.  1  half 
grown);  his  temperature  reached  normal  on  the  18th,  but  on  the  20th  the  temper- 
ature was  100°;  the  temperature  rose  to  103°  on  the  22d;  blood  examination  showed 
the  festivo-autumnal  parasite  on  this  day;  no  tertian  parasites;  Widal,  negative. 
Blood  v/as  examined  daily;  the  sestivo-autumnal  parasites  (ovoids,  crescents,  and 
round  bodies)  were  found  in  gradually  lessening  numbers  until  the  27th  day  of 
November,  i.  e. ,  up  to  the  8th  day  of  continuous  fever,  then  they  disappeared;  the 
temperature  came  down  to  normal  after  nineteen  days  of  fever;  the  highest  point 
recorded  on  the  temperature  chart  was  10-1  on  November  27.  After  repeated 
examinabions  for  Widal,  a  positive  reaction  was  obtained  on  the  25th  day  of  the 


157 

disease  (after  the  temperature  had  been  normal  nearly  a  week).  The  man's  tem- 
perature remained  normal  until  December  26,  when  he  had  a  sharp  chill,  the  tem- 
perature rising  to  106";  the  temperature  fell  to  normal,  but  was  followed  by 
another  chill  and  rise  to  103.4°  on  the  next  day.  Examination  of  blood  showed 
double  tertian  (two  crops  of  the  malarial  parasite).  The  first  chill  occurred  after 
eighteen  days  of  normal  temperature. 

In  these  9  cases  the  malarial  infection  was  in  5  single  tertian,  in  2  double  tertian, 
and  in  2  double  tertian  and  festivo-autumnal. 

We  have  found  malaria  complicating,  or  rather  recurring,  during  the  convales- 
cence from  other  diseases,  and  even  in  surgical  cases.  There  appears  to  be  no 
connection  between  typhoid  and  malaria  other  than  that  an  attack  of  typhoid 
fever,  by  lowering  the  individual's  resisting  powers,  gives  favorable  soil  for  a 
recurrence  of  his  malaria,  or  affords  a  suitable  condition  for  a  fresh  invasion  by 
the  malarial  parasite. 

Probably  careful  investigation  would  reveal  the  fact  that  convalescents  from 
diseases  other  than  typhoid  show  quite  as  large  a  pei'centage  complicated  by 
malaria. 

Acting  Asst.  Surg.  James  Carroll,  U.  S.  Army,  who  made  blood 
examinations  at  both  Camp  Alger,  Va.,  and  Jacksonville,  Fla.,  failed 
to  find  the  malarial  parasite  in  the  cases  of  fever  examined  by  him. 

Dock,  of  Ann  Arbor,  who  was  assigned  to  duty  at  Chickamauga 
during  the  early  part  of  September,  1898,  and  afterwards  visited  the 
camps  at  Knoxville,  Tenn.,  and  Middletown,  Pa.,  sums  up  the  result 
of  his  painstaking  labors  as  follows : 

I  found  no  evidence  of  combined  typhoid  and  malarial  infection.  Among  so 
large  a  number  of  cases  of  typhoid  fever  in  men  from  all  parts  of  the  country 
some  cases  of  that  kind  must  have  occurred. 

Dr.  James  Ewing,  who  was  detailed  by  Surgeon-General  Sternberg 
to  duty  at  Montauk  Point,  N.  Y.,  to  render  what  assistance  blood 
examinations  might  give  in  the  diagnosis  of  fevers  among  troops 
arriving  from  Cuba,  makes  the  following  valuable  observations : 

In  69  cases  giving  a  distinct  history  of  recent  malarial  fever  and  exhibiting 
similar  evidence  in  the  blood  in  the  form  of  severe  anaemia,  pigmented  leucocytes, 
often  atypical  pigmented  intracellular  bodies,  and  in  some  cases  a  few  plasmodia, 
the  question  of  a  double  infection  with  typhoid  fever  and  malaria  had  to  be 
considered. 

Of  these,  40  were  reported  as  cases  of  typhoid  fever  in  anaemic  and  malarious 
subjects.  In  some  of  these  cases  the  disease  began  with  one  or  more  short  rigors 
repeated  on  successive  days,  after  which  the  disease  progressed  with  the  usual 
symptoms  of  typhoid  fever.  In  one  such  instance  (791)  tertian  parasites  were 
found  during  the  first  few  days  and  before  typhoid  fever  was  suspecced,  but  they 
disappeared  rapidly  under  quinine  and  were  not  again  seen.  The  patient  died 
from  peritonitis  in  the  fourth  week. 

In  another  case  (514)  the  usual  history  of  Cuban  malaria  was  interrupted  by 
the  development  of  typhoid  fever  with  all  essential  symptoms;  plasmodia  could 
not  be  found  in  the  blood,  but  in  the  second  week  of  convalescence  tertian  chills 
and  fever  developed  and  tertian  parasites  were  found  in  the  blood. 

In  a  third  case  (683)  the  history  indicated  the  slow  onset  of  typhoid  fever  in 
Cuba,  which  was  safely  withstood  without  quinine,  but  in  the  second  week  of 
convalescence,  tertian  chills  and  fever  supervened  and  tertian  parasites  were 
found  in  the  blood. 


158 

There  were  other  cases  (1.  3.  ol,  115,  etc. )  illtistrating  the  same  behavior  of  the 
malarial  infection  durino;  the  course  of  typhoid  fever. 

Further  evidence  of  the  usual  incompatibility  of  malarial  and  typhoid  fevers 
were  furnished  by  the  2  fatal  cases  of  typhoid  fever  in  malarious  subjects  tbat 
came  to  autopsy  (533. 683).  There  no  parasites  could  be  found  in  the  blood  dur- 
ing life,  but  in  smears  from  the  spleen  and  marrow  diligent  search  revealed  the 
presence  of  a  very  few  rings  and  crescents,  with  much  old  malarial  pigment. 

The  reason  why  the  blood  was  examined  in  159  cases  of  typhoid  fever,  was  the 
intermittent  character  of  the  fever,  which  was  exhibited  in  patients  both  with 
and  without  malarial  antecedents.  In  no  case  of  undoubted  and  established 
typhoid  fever  were  malarial  parasites  found  in  the  blood  in  connection  with  any 
of  these  sudden  rises  of  temperature,  but  only  at  the  onset  of  the  disease  or  dur- 
ing convalescence. 

On  the  other  hand,  many  patients  whose  blood  contained  numerous  parasites 
were  seen  in  the  typhoid  state,  but  there  was  always  some  essential  symptoms 
lacking  to  confirm  the  diagnosis  of  typhoid  fever,  while  the  subsequent  course  of 
the  disease,  where  observed,  demonstrated  the  purely  malarial  character  of  the 
fever. 

The  patients  might  suffer  from  epistaxis,  hematemesis,  bloody  stools,  tympa- 
nites, a  few  rose  spots,  though  oftener  herpes,  diarrhea,  and  delirium,  and  in 
some  a  partial  Widal's  reaction  was  obtained.  But  the  intestinal  symptoms  were 
inconstant  or  referable  to  dysentery  or  simple  diarrhea,  from  which  many  of  the 
malarial  cases  suffered,  and  these  patients  never  showed  subsultus,  or  cracked 
tongues,  and  thej^  did  not  die.  or  if  they  did  dysentery  and  malaria  were  demon- 
strated at  or  before  the  autops}-. 

In  another  group  of  29  cases  the  absence  of  any  large  number  of  parasites  and 
presence  of  typhoidal  symptoms  left  a  reasonable  doubt  regarding  the  diagnosis. 

These  cases  seemed  almost  certainly  malarial  on  account  of  the  previous  history, 
the  fades,  the  aneemia,  and  usually  the  sudden  recovery  at  the  turn  of  the  disease, 
while  in  ~  of  them  a  few  parasites  were  found  in  the  blood. 

On  the  other  hand,  the  suspicion  of  tj^phoid  fever  was  raised  by  the  continued 
fever,  abdominal  symptoms,  and  general  typhoidal  state,  although  symptoms  of 
typhoid  fever  were  not  present  in  distinct  and  convincing  form.  A  moderate 
reaction  with  Widals  test  was  sometimes  obtained  in  these  cases,  but  this  evidence 
failed  to  be  convincing  after  sharp  reaction  had  occuiTed  in  a  case  of  dysentery 
(269)  and  in  a  cinchonized  case  of  pernicious  malaria  (328). 

It  is  possible  that  some  of  these  patients  suffered  from  both  active  malaria  and 
typhoid  fever,  but  there  was  no  positive  indication  that  the  latter  infection  was 
present.  In  the  cases  that  came  to  autopsy  there  was  never  any  doubt  of  the 
nature  of  the  disease.  It  was  either  typhoid  fever  or  malaria,  but  never  both, 
although  microscopical  evidence  of  dormant  malarial  infection  was  found  in  at 
least  2  cases  of  typhoid  fever. 

In  short,  in  spite  of  every  painstaking  effort  the  attempt  to  find  a  case  of  tjT)hoid 
fever  and  active  malaria  progressing  simultaneously  was  "ansuccessful. 

From  the  study  of  this  group  of  cases  it  is  concluded: 

(1)  That  typhoid  fever  is  to  a  large  extent  incompatible  with  active  malarial 
fever,  and  that  during  the  course  of  the  former  the  latter  infection  is  usually 
suppressed. 

(2)  That  the  presence  of  old  malarial  infection  may  alter  the  course  of  typhoid 
fever  through  the  anaemia,  but  that  active  sporulation  of  the  malarial  parasites 
very  rarely  occurs  during  the  course  of  established  typhoid  fever. 

(3)  On  the  other  hand,  since  malarial  paroxysms  often  reappear  during  con- 
valescence, a  scanty  growth  of  the  parasite  must  often  persist  during  the  course 
of  typhoid  fever,  and  it  is  possible  that  some  of  the  irregularities  of  temperature 
observed  in  these  cases  are  referable  to  this  partly  suppressed  growth. 


159 

( 4)  That  the  anatomical  evidence  of  a  post-mortem  examination  is  much  needed 
to  demonstrate  the  existence  of  typhoid  fever  in  cases  showing  active  malarial 
paroxysms. 

Acting-  Asst.  Surg.  Charles  Craig/  U.  S.  Army,  wko  spent  several 
months  at  the  Sternberg  Hospital,  Chiekamauga  Park,  Ga. ,  reports 
a  case  of  combined  typhoid  and  quartan  malarial  fever,  the  first  case 
to  be  placed  on  record  in  which  the  quartan  parasite  has  been  found. 

History. — Male;  malaise. constipation,  and  headache,  with  eveningtemperature 
of  from  101^  F.  to  102'  F.  from  September  29  to  October  5,  on  which  date  he 
was  admitted  to  hospital.  The  previous  evening  he  had  a  slight  chill.  On 
admission  the  sj^mptoms  were  gurgling  and  tenderness  in  right  iliac  fossa:  dry, 
hot  skin  and  typhoid  tongue.  Later  there  was  tympanites,  epistaxis,  and  rose 
spots. 

October  12,  or  about  the  twelfth  day  of  disease,  Widal  reaction  pronounced. 

15th. — Temperature  a.  m.,  100°  F.,  when  he  had  a  slight  chill  with  rise  of  tem- 
perature to  103.4"''  F.  Evening  temperature  101'  F.,  and  for  the  succeeding  two 
days  it  ranged  from  101°  F.  and  103'  F. 

IStJi. — Seventy-two  hours  after  the  first  chill  a  second  and  severer  chill  occurred. 
Examination  of  the  blood  showed  the  quartan  parasite  in  abundance.  The 
patient's  general  condition  was  markedly  worse. 

£lst. — A  third  paroxysm,  the  temperature  rising  from  99.2°  F.  to  104.6°  F.  This 
was  followed  by  a  fourth  and  fifth  paroxysm  on  October  25  and  38.  Large  doses 
of  quinine  prevented  their  return.     The  case  terminated  fatally. 

Craig's  description  of  the  parasite  and  the  chart  accompanying  the 
description  prove  that  the  organism  was  of  the  quartan  variety. 

Da  Costa  ^  reports  10  cases  of  typhoid  fever  among  soldiers  under 
treatment  at  the  Pennsylvania  Hospital,  proved  to  be  such  by  clinical 
symptoms,  and  in  nearlj^  every  instance  by  the  Widal  test,  in  which 
also  the  malarial  parasite,  generally  of  the  tertian  variety  or  of  the 
gestivo- autumnal  type,  was  present. 

The  soldiers  came  from  Camp  Meade,  Pa.,  except  one,  who  had  been 
in  Porto  Rico. 

Da  Costa  says  that  attention  is  nearly  always  called  to  the  malarial 
complication  by  the  occurrence  of  a  chill.  These  chills  came  on  late, 
and  sometimes  not  until  a  relapse.  In  only  one  instance  of  the  10  did 
the  chill  happen  in  the  early  part  of  the  typhoid  fever.  In  1  case  the 
chill  occurred  on  the  twenty-sixth  and  twenty-eighth  days  of  the 
disease,  and  the  tertian  parasite  was  found  on  the  latter  date.  In  a 
second  case,  "late  in  the  disease,  rises  of  .temperature  occurred  from 
normal  to  100.8°,  without  chills;  the  malarial  organisms  of  tertian 
type  were  found  during  these  fever  rises."  In  a  third,  the  chill 
occurred  on  the  fifth  day  after  admission,  followed  by  a  temperature 
of  106°.  Tertian  parasites  in  unusual  number  were  found.  In  a 
fourth  case  the  chills  occurred  on  the  forty-seventh  day  of  the  disease ; 
the  type  of  the  Plasmodium  was  not  well  defined. 

Da  Costa  gives,  as  a  striking  illustration  of  late  appearance,  a  case 


'The  Philadelphia  Medical  Journal,  June  17,  1899. 

=* "  Malaria  with  typhoid  fever."    The  Philadelphia  Medical  Journal,  May  6, 1899. 


160 

in  whicli  it  was  only  during  the  third  relapse  and  on  the  eighty-eighth 
day  of  the  disease  after  a  hard  chill  that  malarial  organisms  were 
foimd.  The  author's  experience  teaches  him  that  cases  of  mixed 
malarial  and  typhoid  infection  are  distinguished  by  chills  and  by  the 
long  duration  of  the  fever. 

Muehleck,^  as  the  result  of  the  careful  study  of  the  blood  of  90  sol- 
diers admitted  to  St.  Agnes  Hospital,  Philadelphia,  reports  the  pres- 
ence of  the  malarial  parasite  in  7  instances.  Dr.  Muehleck  has  kindly 
informed  us  that  in  all  the  cases  in  which  the  parasite  was  found  the 
soldiers  had  come  from  Porto  Rico  or  Cuba.  The  period  of  the  dis- 
ease at  which  the  parasite  was  found  was  as  follows:  During  the 
second  week,  1;  third  week,  1;  fourth  week,  3;  undetermined,  2. 

The  varieties  of  the  parasite  are  not  stated.  They  are  described  as 
"  extracorpuscular  or  intracorpuscular  bodies,  which  in  some  instances 
contained  pigment.  These  bodies  were  spherical,  irregular  in  outline, 
and,  as  first  stated,  sometimes  contained  pigment  which,  at  least  in 
the  intracellular  variety,  was  usually  gathered  in  or  near  the  center  of 
the  body.  In  two  instances  sluggish,  amoeboid  motion  was  observed, 
while  in  the  rest  the  bodies  were  quite  motionless.  *  *  *  Evidences 
of  rosette  formation  or  of  sporulation  were  never  observed,  nor  did 
we  ever  succeed  in  finding  rings,  crescents,  or  ovoid  bodies  belonging 
to  the  sestivo-autumnal  variety. " 

Withington  ^  reports  3  cases  of  typhoid  fever  coincident  with  mala- 
rial infection  and  4  cases  of  typhoid  in  which  the  parasite  was  found 
during  convalescence.  Withington's  cases  occurred  among  soldiers 
who  had  returned  from  Cuba;  the  variety  of  the  parasite  was  ?estivo- 
autumnal  in  6  cases ;  in  1  the  variety  is  not  stated. 

The  history  of  one  of  the  coincident  infections  with  malaria  and 
typhoid  is  as  follows: 

J.  A.  F.,aged  18,  of  the  Second  Massachusetts  Volunteers,  was  sick  and  in  the 
hospital  in  Cuba  about  July  18  with  chills  and  fever.  At  that  time  some  vomiting 
and  diarrhea,  with  bloody  stools.  Came  to  Montauk  Point  and  thence  went  to 
his  home  in  Orange,  Mass.,  but  did  not  feel  well  at  either  place.  About  Septem- 
ber 10  had  chills  and  fever  for  five  days. 

Entered  the  hospital  September  24,  at  which  time  he  had  had  no  chill  for  eight 
days.  Some  diarrhea,  but  lately  constipation.  The  enlarged  spleen  could  be  felt, 
and  there  was  a  limited  number  of  rose  spots.  The  plasmodia  malarise  were  found. 
The  Widal  test  was  negative  on  September  30.  On  the  night  of  October  4  he  was 
seized,  while  in  the  act  of  defecation,  with  some  pain  in  the  abdomen,  and  the  tem- 
perature dropped  2  .  The  next  morning  the  abdomen  was  found  moderately  dis- 
tended, muscles  rigid,  tympany  general  except  in  left  flank,  where  there  was  dull- 
ness.    He  failed  during  the  day  and  died  at  10.45  p.  m.  October  5. 

The  autopsy  showed  a  marked  malarial  spleen,  much  enlarged  (weight  430 
grams),  symmetrical,  of  dark,  slate  color.     The  follicles  could  not  be  made  out; 

1  "Results  of  the  examination  of  the  blood  of  90  soldiers  ill  with  typhoid  at  the 
St.  Agnes  Hospital.'^    The  Philadelphia  Medical  Journal,  May  20,  1899. 

2 "Coincident  malaria  and  typhoid  infections  as  seen  among  our  returned  sol- 
diers."   Report  of  the  Boston  City  Hospital,  1899. 


161 

spleen  fairly  firm,  little  pulp  on  scraping;  microscopically,  much  black  pigment  in 
the  cells.  There  were  also  numerous  typhoid  ulcers,  one  of  which,  at  a  point  55 
«m.  above  the  ileocsecal  valve,  had  perforated  the  bowel,  causing  general  fatal 
peritonitis. 

The  author  also  records  4  cases  in  which,  as  he  states,  the  probabil- 
ity seems  very  strong  of  a  typhoid  supervening-  upon  a  malaria. 
We  quote  the  history  of  one  of  these  cases . 

J.  W.,  aged  25,  Seventh  U.  S.  Infantry.  Two  weeks  before  leaving  Cuba  had 
chills  and  fever  for  six  days.  Recovered.  Again  chills  and  fever  on  transport 
from  Cuba.  Felt  well  while  at  Montauk  until  September  5.  Then  malaise,  head- 
ache, and  diarrhea.  Entered  hospital  September  13.  Rose  spots;  Wldal  reaction 
positive;  no  plasmodia.  His  temperature  ran  a  fairly  characteristic  typhoid 
course,  becoming  normal  on  October  13.  On  the  18th  a  chill  while  in  bath.  Tem- 
perature rose  3'  and  returned  to  normal.  No  search  for  plasmodia  appears  to 
have  been  made  on  this  day.  For  the  following  week  there  was  some  fever,  which 
was  supposed  to  be  a  recrudescence  of  the  typhoid.  A  slow  recovery  with  great 
prostration.     The  record  shows  no  plasmodia  at  any  time. 

Concerning  these  cases,  ^yithington  says : 

The  evidence  of  primary  malarial  infection  while  in  Cuba  is  as  strong  as  it  can 
be  without  microscopic  demonstration .  but  the  malaria  was  generally  in  abeyance 
during  the  progress  of  the  typhoid,  the  latter  disease  running  its  course  in  some 
cases  typically,  in  others  more  or  less  atypically. 

The  author  also  records  3  cases  in  which  the  sequence  was  (1) 
malaria,  (2)  typhoid,  (3)  malaria,  and  remarks  that  "each  of  these 
seemed  to  hold  the  field  alone  for  the  time  being,  the  original  malaria 
becoming  dormant  while  the  tj'phoid  was  in  progress,  so  that  the 
latter  disease  was  in  all  respects  unmodified,  and  then  with  recovery 
of  the  t}^hoid  the  malaria  reasserted  itself  as  before." 

The  following  case  is  given  in  illustration : 

J.  C.  G. ,  aged  23,  Fourth  U.  S,  Infantry.  Had  a  sudden  onset  of  fever  August 
25.  There  were  chills,  fever,  and  sweating  of  daily  occurrence.  Says  he  was 
cured  of  this  at  Montauk.  Entered  hospital  September  6.  Diarrhea;  five  or  sis 
dejections  daily;  green  to  dark;  slimy:  twice  bloody.  Pain  and  tenderness  about 
umbilicus.  No  plasmodia  found.  The  fever  reached  normal  for  one  day,  Septem- 
ber 13;  for  the  next  ten  days  ran  about  100',  and  on  September  23  the  Widal  test 
was  positive.  From  September  28  the  fever  was  higher  (102"),  but  had  gone 
by  October  6,  and  the  patient  was  convalescent.  October  20  plasmodia  were 
present,  the  patient  having  on  that  day  a  chill  which  shook  the  bed,  with  tem- 
perature nearly  to  105  .  There  was  no  further  manifestation  of  the  disease 
after  this. 

From  the  Massachusetts  General  Hospital,  through  the  kindness  of 
Dr.  Yickey,  we  are  able  to  report  the  following  cases: 

Case  I. — Soldier;  age,  28;  regular;  Cuban  service.  Admitted  August  23,  1898. 
Widal  positive:  crescents  in  blood;  afebrile  after  first  day.  Diagnosis:  Malarial 
remittent-typhoid  convalescent.  Transferred  to  another  hospital.  Had  another 
relapse,  but  whether  typhoid  or  malaria  is  unknown.     Termination  unknown. 

Case  II. — Soldier;  age,  24;  regular;  Cuban  service.  Admitted  September  6. 
Widal  positive  and  ovoids  on  September  10.  Diagnosis:  Typhoid  fever-malarial 
7273 11 


162 

remittent.  Temperature  very  irregnlar:  remained  subnormal  after  three  days; 
quinine  administered.     Recoveiy. 

Case  ill. — Soldier;  age,  26;  Volunteer;  Cuban  service.  Admitted  Septembers. 
Widal  positive;  chill  on  day  of  entrance  with  a  temperature  of  lOo.o.  Double 
tertian  parasites.  Quinine  administered  with  no  further  rise  of  temperature. 
Recovery. 

Case  IV. — Soldier;  age,  22;  Regular;  Cuban  service.  Admitted  September  13. 
Widal  positive.  Symptoms  quite  typical  of  typhoid.  Tertian  (?)  parasites;  no 
marked  irregularity  of  temperature  due  to  malaria.  Dr.  Shattuck  thinks  the 
malarial  complication  probably  remittent.     Recovery. 

Case  v.— Soldier;  age,  23;  Regular;  Cuban  service.  Admitted  October  15. 
Widal  positive;  tertian  parasites  in  blood;  afebrile  after  first  day.     Recovery. 

Through  the  kindness  of  the  medical  superintendent  of  the  Lakeside 
Hospital,  at  Cleveland,  Ohio,  we  are  able  to  report  the  following  cases 
in  which  the  blood  examination  was  made  by  Dr.  E.  P.  Carter: 

Case  I. — B.  P. ,  Company  F,  Fifth  Ohio  Volunteers.  Blood  examination  showed 
both  the  Widal  reaction  and  the  sestivo-autumnal  parasite.     Death  resulted. 

Case  II.— J.  R.,  Company  A.  Fifth  Ohio.  Blood  examination  showed  both  the 
Widal  reaction  and  the  malarial  parasite.  The  form  of  the  latter  is  not  stated. 
Patient  recovered. 

Case  III. — G.  R.,  Company  C,  Fifth  Ohio.  Blood  examination  showed  both  the 
Widal  reaction  and  the  Plasmodium  malaria.  The  variety  of  the  latter  is  not 
stated.     Patient  lecovered. 

Case  IV. — C.  G.,  Company  B,  Fifth  Ohio.  Blood  examination  showed  the  Plas- 
modium and  gave  Widal  reaction.    Variety  of  parasites  not  stated.    Recovery. 

Case  V. — A.  H.,  Company  L,  Fifth  Ohio.  Blood  examination  showed  the  Plas- 
modium and  gave  Widal  reaction.  Type  of  parasite  is  not  stated.  Termination 
no':  given. 

Case  VI. — J.  J.  F..  Battery  A.  Blood  examination  showed  both  the  Widal 
reaction  and  the  aestivo-autumnal  parasite.  This  man  developed  amoebic  dysen- 
tery and  died. 

C.  R.  Grandy^  (tj^pho-malarial  fever)  reports  two  cases: 

Case  I. — Had  a  chill  in  Santiago;  was  quite  ill;  but  recovered  sufficiently  to 
come  to  this  country;  went  to  Camp  Wickoif,  Montauk  Point,  L.  I. 

August  27. — Had  a  chill,  with  temperature  lOo'. 

28th.— Blood  contained  pigmented  tertian  parasites.  Attack  responded  to  qui- 
nine. 

September  11. — Patient  had  chill. 

13th. — Two  sets  of  tertian  parasites. 

19th. — Widal  positive.     The  fever  then  ran  the  course  of  typical  typhoid  fever. 

October  19. — Fever  disappeared. 

23d.  —  Chill,  followed  by  fever  and  sweat.  Malarial  organisms  were  again  found 
in  the  blood.  Malarial  parasites  preceded  the  fever,  present  at  beginning,  dor- 
mant during  height,  and  then  returned. 

Case  II.— Four  days  before  the  patient,  a  healthy  young  man,  had  had  a  slight 
chill  followed  by  fever:  the  next  day  there  was  a  remission,  but  not  a  comp.ete 
intermission.  The  fever  then  became  very  iiregular,  bat  did  not  rise  above  103'  F. 
Upon  examination  there  was  headache,  constipation,  enlargement  of  the  spleen, 
temperature  of  103  F.  Blood  examination  showea  pigmented  tertian  parasites 
within  the  red  cells;  Widal  reaction  absent.     Quinine  was  given,  and  the  fever 

^  New  York  Medical  Journal,  September  30, 1899. 


163 

dropped  to  not  quite  normal;  afterwards  it  rose  gradually  and  the  patient  developed 
a  case  of  typhoid  fever,  from  which  he  recovered  without  a  return  of  the  malarial 
symptoms. 

In  addition  to  the  foregoing  eases  which  we  have  quoted  at  some 
length,  we  have  obtained  data  concerning  6  other  cases  of  so-called 
mixed  malarial  and  typhoid  infection,  as  given  in  a  discussion  before 
the  College  of  Physicians  of  Philadelphia  Februarj^  1,  1899,  con- 
cerning the  experiences  in  the  hospitals  of  Philadelphia  with  typhoid 
fever  originating  among  the  soldiers  in  the  late  war. 

Dr.  Arthur  C.  Meigs  reported  2  cases  of  typhoid  fever  under  treat- 
ment at  the  Pennsylvania  Hospital,  in  which  there  was  a  return  of  fever 
after  convalescence  seemed  to  have  been  fully  established.  Exami- 
nation of  the  blood  showed  the  presence  of  the  Plasmodium  malarise ; 
the  variety  was  not  stated.     Recovery  followed  under  quinine. 

Dr.  Alfred  Stengel  at  the  same  meeting  stated  that  he  had  observed 
2  cases  of  typhoid  fever  in  which  the  malarial  parasite  had  been  found 
during  convalescence;  the  variety  was  tertian.     Recovery  followed. 

Finally,  W.  H.  Thompson  ^  reports  2  cases  of  typhoid  fever  in  which 
attacks  of  chills  and  fever  occurred  during  convalescence,  and  in 
which  microscopic  examination  of  the  blood  showed  the  Plasmodium 
malarias;  variety  not  stated.     Patient  recovered. 

In  the  following  table  we  have  endeavored  to  arrange,  as  far  as  pos- 
sible, all  of  the  cases  cited  by  us : 

Mixed  malarial  and  typhoid  infection. 


Date. 

Author. 

iS^f      Time  of  malarial 
^clses'               ^"^°t- 

Variety  of  parasite. 

Termination. 

188i 

Laveran 

do 

1 
1 

1 

1 

1 
1 

1 

1 

1 

9 

7 
1 

1 

During       convales- 
cence from  typhoid. 

Preceding    the    ty- 
phoid and  during 
convalescence. 

At    commencement 
of  the  typhoid. 

Coin'-ident  with  the 
typhoid. 

During       convales 
cence. 

Doubtful 

Tertian            .  . 

Recovery. 
Do 

do 

1890 

Kinyoun. 

do 

Not  stated 

Do. 

....  do 

Death      (peritonitis, 

pneumonia). 
Recovery. 

Do 

do 

....  do 

do 

.      do- 

1894 

Thompson 
(W.  G.). 
do 

do 

Do. 

During       convales 
cence. 

Preceding   the    ty- 
phoid 6  days. 

Preceding    the    ty- 
phoid 3U  days. 

At  commencement.. 

..      do 

do 

Do. 

1895 

Osier 

Do. 

do 

.^stivo-autumnal  -.. 

Described  as  amoebic 
and      segmenting 
forms    and    cres- 
cents. 

do 

Do. 

Vincent 

do 

Do. 

Death  (myocarditis, 
nephritis,          gan- 
grene of  the  lung, 

do. 

Parasites  found   at 
autopsy. 

Not  stated 

do 

pneumonia,         ab- 

1897 

Da  Costa 

Not  stated 

scess  of  the  kidney 
and     spleen,    peri- 
tonitis, etc.) 
Recovery. 

'  "Acute  malarial  fever,"  New  York  Medical  Record,  December  10,  1898. 


164 

Mixed  malarial  and  typhoid  infection — Continued. 


Date. 


1898 


Author. 


Num- 
ber of 
cases. 


Lyon 

Curry 

....do... 

....do... 
..-.do.... 

....do... 

Ewing  . . 

....do... 

do... 

Craig  ... 

Da  Costa 
do... 

do... 

do... 

do... 


Muehleck . 

do 

do 


1898 


.do. 


Withington. 


-do. 
-do. 


Massachusetts 
general  hos- 
pital. 

do 


do 

do 

do. 

Cleveland 
Lakeside 
Hospital. 

do 


do... 

Grandy 


do. 

Meigs  . 


Stengel 

Thompson 
(W.H.). 


Time  of  malarial 
attack. 


convales- 


first 


During 
cence. 

Coincident, 
week. 

On  the  eighteenth 
day  of  convales- 
cence. 

During  convales- 
cence. 

do 

do.-.. 


2  to  6  months  after 
the  typhoid. 

Immediately  pre- 
ceding. 

During  convales- 
cence. 

do 

Coincident,  eight- 
eenth day. 

Coincident,  fifth  day 

During  convales- 
cence, twenty- 
eighth  day. 

During  third  re- 
lapse, eighty- 
eighth  day. 

During  convales- 
cence, forty-sev- 
enth day. 

During  convales- 
cence. 


Coincident,  second 
week. 

Coincident,  third 
week. 

During  convales- 
cence, fourth 
week. 

Undetermined 


Variety  of  parasite. 


Coincident . 


....do 

During       convales- 
cence. 
Coincident 


During 

cence. 

do.. 

do.. 

do_- 

do.- 


convales- 


-do. 
.do 


Immediately  preced- 
ing and  during  con- 
valescence. 
At  commencement - 
During       convales- 
cence. 


-do. 
.do. 


Tertian 

Aestivo-autumnal. . . 
Double  tertian 

Single  tertian 

Double  tertian 

Double  tertian ; 

sestivo-autumnal. 

Not  stated 

Tertian --. 

do-... 

Not  stated 

Quartan  .  -  _ 

Tertian 

do 

do 

Not  stated... 


Tertian  or  jS^stivo- 
autumnal;  gener- 
ally the  former. 

Variety  not  deter- 
mined. Extracor- 
puscular  or  intra- 
corpuscular  bod- 
ies in  some  in- 
stances containing 
pigment;  bodies 
spherical,  irregu- 
lar in  outline,  and 
in  the  intracellu- 
lar variety  pig- 
ment usually  gath- 
ered in  or  near  t  he 
center. 

Not  stated. -.. 


Termination. 


Recovery. 


Do 


Do. 

Do. 
Do. 

Do. 

Death,  fourth  week 

(peritonitis). 
Recovery. 

Do. 

Death. 

Recovery. 
Do. 


Do. 


Do. 


Do. 


u^stivo-autumnal . 
do 


Doubtful 


Tertian  , 


.^stivo-autumnal . . . 
do 

Double  tertian 

.^stivo-autumnal . . . 


-do. 


Not  stated - 
Tertian 


do 

Not  stated. 


Tertian 

Not  stated. 


Do. 
Do. 


Do. 


Do. 


Death,   twelfth  day 

(perforation). 
Recovery. 
Do. 

Do. 


Do. 

Do. 

Doubtful. 
Recovery. 

Death     (cause      not 
stated). 

Death  (amoebic  dys- 
entery). 
Recovery. 
Do. 


Do. 
Do. 


Do. 
Do. 


165 

From  this  table  we  are  able  to  make  the  following  distribution  of 
cases  according  to  the  time  when  the  malarial  parasite  was  observed 
in  the  blood;  also  the  number  of  deaths: 

Distribution  of  cases  according  to  the  time  when  the  malarial  parasite  ivas 
observed  in  the  blood;  also  number  of  deaths. 


Distribution. 


Number 

Number 

of 

of 

cases. 

deaths. 

3 

1 

2 

0 

18 

7 

12 

i 

52 

2 

3 

0 

4 

0 

1 

1 

95 

15 

Preceding  the  typhoid _ 

Preceding  the  typhoid  and  also  during  the  convalescence. 

At  the  commencement  of  the  typhoid 

Coincident  with  the  typhoid. 

During  convalescence 

Two  to  six  months  after  typhoid 

Undetermined 

At  autopsy 

Total 


Mortality  rate,  15.7  per  cent. 

It  is  a  matter  of  considerable  regret  that  many  of  the  cases  here 
given  are  not  accompanied  by  anything  like  a  complete  clinical  his- 
tory or  by  detailed  description  of  the  parasite.  In  a  majority  of  the 
cases  there  is  a  mere  outline  of  the  history.  Hence,  any  attempt  at 
a  thorough  analysis  of  these  cases  is  difficult  and  the  result  perhaps 
misleading.  We  will  nevertheless  attempt  to  do  so,  as  far  as  the 
material  at  our  disposal  will  permit. 

First.  As  to  the  variet}^  of  the  parasite.  In  51  cases  this  is  not 
stated,  nor  does  the  accompanying  description  enable  the  type  to  be 
defined.  Of  the  remaining'  44  cases  the  variety  is  recorded  as  ter- 
tian, 22;  sestivo-autumnal,  12;  quartan,  1;  tertian  and  sestivo- 
autumnal,  3;  tertian  and  sestivo-autumnal,  "generally  the  former,"  6. 

Second.  As  to  time  of  occurrence,  there  are  5  cases  (5.2  per  cent) 
reported  as  preceding  the  attack  of  typhoid  fever :  Laveran,  1 ;  Osier, 
2;  Ewing,  1;  Grandy,  1. 

In  two  of  these  cases  the  parasite  was  also  found  during  convales- 
cence: Laveran,  1;  Grandy,  1. 

The  interval  which  preceded  the  observation  of  the  malarial  para- 
site and  the  onset  of  typhoid  fever  was  as  follows:  Laveran's  case, 
15  days;  Osier's  cases,  6  and  30  days,  respectively;  Ewing's  case, 
interval  stated  as  "  a  few  days;  "  Grandj^'s  case,  15  daj^'s. 

Of  the  18  cases  (18.9  per  cent)  in  which  the  parasite  is  recorded  as 
being  present  at  the  commencement  of  the  typhoid  fever,  1  case  is 
reported  by  Kinyoun,  16  by  Vincent,  and  1  b}'  Grandy. 

In  Kinyoun's  case  it  is  stated  that  the  patient  was  taken  sick  two 
days  before  admission,  the  attack  commencing  with  a  chill  followed 
by  fever,  and  that  tlie  parasites  were  at  this  time  in  the  blood  in  large 
numbers;  six  days  later  rose  spots  were  seen,  followed  by  epistaxis,  etc. 

In  Vincent's  cases  nothing  further  is  stated  than  that  the  micro- 


166 

scopic  examination  of  the  blood  was  made  during  life  and  at  the  onset 
of  the  disease  (  "pendant  la  vie  et  au  debut  de  I'affection"). 

In  Grandy's  case  a  slight  chill  followed  by  fever  had  occurred  on 
the  fourth  daj^  preceding  the  examination  of  the  blood,  an  irregular 
fever  occupying  the  intervening  days.  Upon  the  administration  of 
quinine  the  temperature  dropped,  but  not  quite  to  normal. 

It  is  worthy  of  observation  that  of  the  23  cases  (24.2  per  cent)  in 
which  the  parasite  was  observed  within  a  few  days  preceding  the 
attack,  or  at  the  commencement  of  the  typhoid  fever,  in  none  of  these 
was  its  presence  recorded  during  the  acute  stage  of  the  fever,  and  in 
only  2  cases  during  convalescence.  The  disappearance  of  the  para- 
site was  probably  due  in  part  to  the  administration  of  quinine. 

In  54  cases  (56.8  per  cent)  the  presence  of  the  parasite  is  recorded 
as  occurring  during  convalescence  from  the  typhoid  fever;  and  in  2  of 
these  cases  it  was  also  seen  during  the  period  preceding  the  attack. 

The  period  during  convalescence  at  which  the  parasite  was  found 
was  as  follows:  First  week,  3  cases;  second  week,  5;  third  week,  4; 
fourth  week,  2;  sixth  to  twelfth  week,  7;  undetermined,  33. 

In  4  cases  (4.2  per  cent) :  Kinyoun,  1 ;  Da  Costa,  1 :  Muehleck,  2.  The 
time  of  the  observation  of  the  presence  of  the  parasite  in  the  blood 
can  not  be  determined. 

In  1  case  (1.05  per  cent)  reported  by  Vincent  the  parasites  were 
found  at  the  autopsy. 

In  3  cases  (3.1  jDer  cent)  reported  by  Curry  chronic  forms  of  the 
aestivo-autumnal  parasite  were  found  two  to  six  months  after  the 
attack  of  typhoid  fever. 

In  12  cases  (12.6  per  cent)  the  parasite  was  found  in  the  blood  dur- 
ing the  active  stage  of  tj'phoid  fever,  and  hence  these  are  the  only 
cases  that  properly  belong  under  the  head  of  coincident  malarial  and 
tjTphoid  infection.  As  regards  the  previous  history  of  malaria  in  these 
concurrent  infections,  this  was  positive  in  1  case,  negative  in  3  cases, 
while  8  pati(mts  had  been  residing  in  malarial  climates  at  some  time 
shortl}-  preceding  the  onset  of  typhoid  fever  (Cuba,  6;  tidewater 
region  Virginia,  2).  The  variety  of  the  parasite  found  in  these  12 
cases  was:  Tertian,  1;  quartan,  1;  testivo-autumnal,  3;  undeter- 
mined, 7. 

The  mortality  in  these  coincident  infections  was  33^  per  cent,  or 
more  than  double  that  of  the  mortalitj*  given  for  all  the  cases  recorded 
in  our  table,  viz,  15.7  per  cent.  Excluding  the  12  coincident  infec- 
tions, the  remaining  83  cases  give  a  mortality  of  13.2  per  cent. 

We  think  it  probable  that  when  a  larger  number  of  cases  have  been 
reported  the  mortality  rate  will  be  less  than  here  recorded.  That  it 
should  exceed  the  average  mortality  of  typhoid  fever  would  not  be 
surprising,  since  an  individual  the  subject  of  malarial  disease,  even 
if  not  rendered  thereby  more  susceptible  to  tj^phoid  infection  (of 
which  there  is  no  evidence),  would  probably  be  less  able  to  resist  the 
latter  when  once  established. 


167 

When  it  is  remembered  that  these  12  cases  of  coincident  infection 
are  all  that  we  have  been  able  to  collect  after  patient  search,  and  that 
a  stricter  criticism  of  each  individual  case  would  have,  perhaps, 
reduced  even  this  number^  it  will  be  seen  that  these  concurrent  infec- 
tions are  very  rare  and  bear  an  extremely  small  proportion  to  the  total 
number  of  typhoid  cases  that  have  been  subjected  to  microscopic 
examination  of  the  blood  during  the  past  fifteen  years. 

Therefore,  having  already  conclusively  shown  in  other  parts  of  this 
report  that  the  fever  so  prevalent  in  our  military  camps  during  the 
late  Spanish  war,  and  which  was  diagnosed  by  the  majority  of  medical 
officers  as  malarial  remittent  or  typhomalarial  fever,  was  none  other 
than  typhoid  fever,  it  would  not  be  profitable  to  here  further  discuss 
the  nature  of  typhomalarial  fever,  especially  in  view  of  the  results 
obtained  by  a  careful  study  of  all  the  cases  of  so-called  mixed  malarial 
and  typhoid  infection  recorded  in  the  literature. 

It  will  suffice  to  state  that  while  the  opinion  expressed  by  Wood- 
ward, namely,  that  the  poison  of  malaria  and  of  typhoid  fever  could 
be  present  in  the  body  at  the  same  time,  is  shown  to  be  well  founded, 
his  contention  that  the  two  poisons  could  give  rise  to  a  "  hybrid  form 
of  disease,  exhibiting  the  ordinary  symptoms  of  malarial  and  typhoid 
fever  variously  combined,"  is  not  borne  out  by  observation. 

Further,  that  Woodward's  opinion  concerning  the  frequency  of  the 
association  of  the  two  poisons  so  that  "there  was  danger  that  this 
hybrid  form  would  appear  in  epidemic  proportions  whenever  an  army 
recruited  in  a  nonmalarial  region  should  campaign  on  malarial  soil " 
is  proven  to  be  absolutely  without  foundation. 

Rather  do  the  observations  which  we  have  brought  together  appear 
to  indicate  that  when  an  individual  the  subject  of  malaria  is  subse- 
quently infected  by  the  typhoid  bacillus,  the  manifestations  of  the 
malarial  parasite  remain,  as  a  rule,  in  abeyance  during  the  active 
stage  of  the  tj^phoid  infection,  to  reappear  in  a  certain  proportion  of 
cases  during  the  stage  of  debility  attendant  upon  convalescence. 

It  follows  that  the  term  "typhomalarial"  as  applied  to  a  particular 
type  of  fever,  whether  used  in  the  sense  understood  by  Woodward  or 
as  indicating  a  severe  type  of  malarial  disease,  is  equall}^  misleading 
and  should  be  dropped  from  the  nomenclature. 


CHAPTER  XIV. 
GENERAL  STATEMENTS  AND  CONCLUSIONS. 

(-?)  During  the  Spanish  war  of  1898  every  regiment  constituting 
the  First,  Second,  Third,  Fourth,  Fifth,  and  Seventh  Army  Corps 
developed  typhoid  fever. 

This  is  true  of  both  the  volunteer  and  the  regular  commands.  We 
are  aware  of  the  fact  that  several  regiments  have  claimed  freedom 
from  typhoid  fever,  and  it  is  true  that  the  sick  records  of  more  than 


168 

one  command  failed  to  show  any  evidence  of  this  disease;  but  bj 
carefully  tracing  the  sick  to  hospitals  we  have  been  able  to  find  one 
or  more  cases  of  typhoid  fever  in  every  regiment. 

{2)  More  than  90  per  cent  of  the  volunteer  regiments  developed 
typhoid  fever  within  eight  weeks  after  going  into  camip. 

The  following  table  gives  for  106  regiments,  in  which  these  data 
were  ascertained,  the  time  of  assembly  at  the  State  encampment,  the 
date  of  muster  into  the  United  States  service,  the  date  of  arrival  at 
national  encampments,  and  the  date  of  appearance  of  the  first  case  of 
* '  probable  "  and  of  ' '  recognized  "  typhoid  fever. 


Regiments. 


Assembled  at 

state  encarap- 

ment. 


Mus- 
tered 
into 
United 
states 
service. 


Arrived 
at  na- 
tional 

encamp- 
ment. 


Date  of 

first 

case  of 

probable 

typhoid. 


FIRST  ARMY  CORPS. 


FIRST  DIVISION. 


1st  Kentucky 

3d   Wisconsin 

5th  Illinois.- 

4th  Ohio --- 

3d   Illinois. 

4th  Pennsylvania. 
16th  Pennsylvania. 

2d   Wisconsin 

3d   Kentucky 


SECOND  DIVISION. 


31st  Michigan 

160th  Indiana 

1st  Georgia 

158th  Indiana 

6th  Ohio 

1st  West  Virginia . 
1st  Pennsylvania . - 

14th  Minnesota 

2d   Ohio  


THIRD  DIVISION. 


5th  Pennsylvania  . . . 
12th  Minnesota 

8th  Massachusetts  . . 

21st  Kansas... 

12th  New  York 

2d    Missouri 

1st  New  Hampshire 

9th  Pennsylvania  . . . 


THIRD  ARMY  CORPS. 


FIRST  DIVISION. 


14th  New  York . 
1st  Missouri ... 
5th  Maryland  . 
2d  Nebraska.. 
2d  New  York . 
3d  Tennessee . 
1st  Vermont  ... 
8th  New  York . 


SECOND   DIVISION. 


2d   Kentucky  . 

9th  New  York . 

1st  Arkansas . . 

5th  Missouri . . . 

2d  Arkansas . . 
69th  New  York . 

1st  Maine 

52d   Iowa 

1st  Mississippi 


Last  May  . 
Last  April . 
Apr.  26... 

In  April 

do 

do 

do 

Apr.  28 

In  May 


In  April. 

do... 

In  May . . 
In  April. 
Apr.  25 . . 
In  April . 
Apr.  28 . . 
In  April . 
do... 


Apr.  27 . . 
Apr.  29 . . 
May  5  - . . 
In  April - 
May  2... 
May  5  ... 
In  April . 
do... 


In  April . 

do... 

do... 

Apr.  27 . . 
In  April . 

do... 

Apr.l... 
In  April . 


In  April . 
May  2... 
In  April . 

do... 

In  May.. 
In  April . 

do... 

Apr.  26-. 
In  May.. 


June  5 

May  8 
May  7 
May  9 
May  7 
May  10 
May  11 
May  12 
May  21 


May  6 
May  8 
In  May 
May  12 
....do... 
May  10 
May  11 
May  10 
....do... 


May  11 
May  7 
May  8 
May  10 
...do... 
....do... 
May  12 
May  10 


May  13 
...do... 
May  10 
....do... 
May  8 
May  5 
May  16 
May  21 


May  22 
May  10 
May  19 
May  18 
May  27 
May  6 
May  13 
May  25 
May  26 


June  11 
May  15 
May  17 
May  16 
May  17 
May  16 
May  17 

June   2 


May  17 
....do... 
June  17 
May  16 
May  18 
May  20 
May  18 
....do.. 
...do... 


May  20 
....do... 
....do... 
...do... 
...do... 
...do... 
May  22 
May  20 


May  20 
May  21 
...do.  . 
May  23 
May  21 
Mav  24 
...do... 
May  35 


May  26 
....do... 
May  27 
....do... 
May  30 
Mav  27 
May  30 
May  31 
...  do... 


June  19 
May  24 
May  16 
May  17 
.-..do... 
June  1 
May  8 
May  11 
June   9 


June  1 
July  4 
June  6 
....do... 
May  18 
June  6 
May  13 
May  27 
May  20 


May  19 
May  2(J 
May  28 
May  21 
June  6 
May  26 
May  24 
May  31 


May  33 
May  31 
June  35 
May  26 
June  1 
lune  9 
May  26 
June  24 


June  26 
June  10 
June  2 
June  6 
June  4 
June  13 
June  35 
June  8 
June  1 


169 


Regiments. 


Assembled  at 
State  encamp- 
ment. 


Mus- 
tered 
into 
United 
States 
service. 


Arrived 
at  na- 
tional 

encamp- 
ment. 


Date  of 
first 

case  of 
probable 
typhoid. 


Date  of 

first 
case  o£ 
recog- 
nized 
typhoid. 


SECOND  ARMY  CORPS 

FIRST  DIVISION. 

(Camp  Alger,  Va.) 


6:5th  New  York 

rthOhio 

1st  New  Jersey  -_ 

8th  Pennsylvania  .  _  _ -  - , 

13th  Pennsylvania 

13th  Pennsylvania 

6th  Illinois - 

6th  Massachusetts 

8th  Ohio 

3d   Virginia 

1st  Connecticut- 

A  and  C,  Nevf  York  Cavalry 


May3- 

End  April. - 

do 

do 

do 

do_ 

do 

do. 

do 

do 

May 

do 


May  17 
May  11 
May  5 
May  11 
....do-.. 
May  13 
May  11 
May  13 
May  13 
....do... 
May  17 
May  20 


SECOND  DIVISION. 

(Camp  Alger,  Va.) 


33d   Kansas 

159th  Indiana 

3d    New  York 

7th  Illinois  -  - 

6th  Pennsylvania. . 

4th  Missouri 

9th  Ohio  Battalion. 

3d    Missouri 

1st  Rhode  Island  . . 
3d    Tennessee 


FIRST  DIVISION. 

(Camp  Meade,  Pa.) 

1st  Maryland--. 

35th  Michigan 

10th  Ohio  .- - 

3d    Connecticut 

302d    NewYork--- - 

15th  Minnesota _- 

SECOND  DIVISION. 

(Camp  Meade,  Pa.) 

4th  New  Jersey - 

SaSd    NewYork- - -. 

3d    West  Virginia 

5th  Massachusetts 

201st  NewYork- 

1st  Delaware 

3d    Pennsylvania 


End  April j  May  11 

do... I  May  13 

May  17 
May  18 
May  10 
May  16 
May  14 
...do--- 
May  10 
May    7 


May. 

do 

End  April-.. 

May 

do 

do 

End  April... 
do 


FOURTH  ARMY  CORPS. 


Apr.  35 
July  10 
July  5  - 
June  33 
July  SO 
July  5  - 


July  19 . 
July  10. 
June  23. 
June  10. 
July  4.. 
Apr.  26 . 
April-.. 


1st  Ohio 

157th  Indiana . . 
32d    Michigan 

2d    Georgia.. 

.5th  Ohio 


End  April.. 

do 

do 

do 

do 


FIRST   DIVISION. 


1st  Alabama 

3d    Alabama 

1st  Louisiana- 

3d    Louisiana 

1st  Texas 

2d    Texas 

1st  South  Carolina . 


SECOND   DIVISION. 


3d    Illinois 

let  North  Carolina. 

3d    New  Jersey 

1st  Wisconsin 


do 

May. 

End  April  - 

do 

do 

do 

May 


Apr.  36  - 
May  1  - . 
Apr.  27  - 
Apr.  3S- 

1  About. 


May  16 
July  9 
July  1 
July  3 
July  19 
July    9 


July  7 
July  15 
June  25 
June  30 
July  16 
May  9 
May  10 


May  6 
May  10 
May  11 
-...do--. 
....do... 


May    9 

May  16 
May  8 
May  11 
May  10 
May  11 
May  10 


May  16 
May  3 
Mav  13 
May  14 


May  30 
May  31 
....do-.- 
May  18 
May  19 
.-.-do.  . 
May  31 
May  33 
May  19 
June  5 
July  19 
May  23 


May  28 
May  24 
May  29 
June  3 
May  19 
May  27 
May  20 
May  30 
May  38 
May  39 


May  35 
Sept.  16 
Aug.  19 
Sept.  10 
Sept.  14 
Sept.  18 


Oct.  9 
Sept.  13 
Aug.  30 
Sept.  12 
Sept.  9 
Aug.  20 
May  19 


May  16 
May  17 
May  23 
May  31 
....do... 


June  21 
June  30 
June  23 
June  29 
....do... 
June  28 
June   7 


May  23 

June  3 
May  24 


May  18 
May  14 
July  2 
May  15 
June  26 
June  16 
May  15 
June  2 
July  13 
June  6 
Aug.  5 
May  30 


July  37 
June  14 
June  18 
July  10 
May  89 
June  13 
July  19 
June  30 
July  13 
May  29 


.^"lo-'. 
July  16 
Aug.  14 
Aug.  30 
Aug.    3 


Aug.  3 
July  27 
July  10 
Aug.  3 
Aug.  20 
May  21 
May  26 


June  1 
June  10 
July  5 
May  30 
May  21 


May 

June  ... 
June  15 

May 

June  . 
...do... 
May 


May  25 
June  6 
June  29 
June  31 


170 


Regiments. 


FOURTH  ARMY  CORPS— Continued. 
SECOND  DIVISION — Continued. 


50th  Iowa 

9th  Illinois... 

2d    Virginia . 

4th  Virginia  . 
49th  Iowa 


Assembled  at 
State  encamp- 
ment. 


THIRD   DIVISION. 


4th  Illinois 

161st  Indiana 

2d   Mississippi 

6th  Missouri 

3d   Nebraska.- 

2d   South  Carolina 

2d   U.  S.  Volunteer  Cavalry. 


Apr.  26. 
June  27. 
May  10 . 
May  9.. 
Apr.  26 . 


May... 
June . . 
May... 
June . . 

do. 

May... 
April. . 


Mus- 
tered 
into 
United 
States 
service. 


May  17 
July  4 
May  11 
May  9 
June  2 


May  19 
July  11 
May  20 
July  30 
July  1 
May  14 
May    1 


Arrived 
at  na- 
tional 

encamp- 
ment. 


May  25 
Aug.  8 
June  3 
June  7 
June  14 


May  29 
Aug  14 
June  21 
Aug.  15 
July  22 
Sept.  16 
June  28 


Date  of 

first 

case  of 

probable 

typhoid. 


June  20 
July  21 
June  2 
June  11 
June  14 


July  11 
July  16 
June  8 
Aug.  1 
July  26 
June  20 
July  30 


Date  of 
first 

case  of 
recog- 
nized 

typhoid. 


June  16 
July  6 
June   8 

Do. 
July  22 


July  11 
July  16 
June  8 
Aug.  1 
July  26 
June  20 
July  30 


The  foregoing  table  may  be  briefly  summarized  as  follows: 


Number  of 
regiments 
which 
came  to 
national 
encamp- 
ments 
with 
typhoid 
fever. 

Number  of  regiments  which  devel- 
oped typhoid  fever  after  arrival 
at  national  encampments  in — 

2  weeks. 

3  weeks. 

4  weeks. 

Over  4 
weeks. 

Number  of  regiments  with  recognized  cases 
of  typhoid  fever  

35 
41 

18 
30 

13 
15 

8 
5 

33 

Number  of  regiments  with  "recognized  and 

15 

It  will  be  seen  that  we  have  obtained  the  initial  dates  of  the  first 
cases  of  "probable"  and  of  "recognized"  typhoid  fever  in  106  regi- 
ments. If  we  suppose  that  the  cases  of  recognized  typhoid  fever 
were  actually  the  first  cases  of  the  disease,  then  the  following  state- 
ments are  correct: 

(a)  Thirtj^-five  regiments,  or  33.01  per  cent,  reached  the  national 
encampments  with  developed  cases  of  recognized  typhoid  fever. 

(b)  Eighteen  regiments  developed  recognized  typhoid  fever  within 
14  days  after  arriving  at  national  encampments,  thus  making  53  regi- 
ments, or  50  per  cent,  with  recognized  typhoid  fever  within  14  days 
after  reaching  national  encampments. 

(c)  Thirteen  additional  regiments  developed  recognized  typhoid 
fever  within  21  days  after  reaching  national  encampments.  Thus,  3 
weeks  after  arriving  at  the  national  encampments  66,  or  62.26  per 
cent,  out  of  the  106  regiments  had  cases  of  recognized  typhoid  fever. 

(c7)  Eight  additional  regiments  developed  recognized  typhoid  fever 
within  28  days  after  reaching  national  encampments,  thus  making 
the  total  number  of  regiments  with  recognized  tj^phoid  fever  28  days 
after  arrival  74,  or  69.81  per  cent. 


171 


If  our  claim  be  accepted  that  the  cases  designated,  as  probable 
typhoid  fever  were  really  due  to  this  disease,  the  following  conclu- 
sions may  be  drawn : 

(a)  Forty-one,  or  38.67  per  cent,  reached  the  national  encampments 
with  cases  of  typhoid  fever  already  developed : 


5th  Illinois. 

3d  Illinois. 
16tli  Pennsy'.vania. 

2d  Wisconsin. 
6th  Ohio. 


65th  New  York. 
7th  Ohio. 
6th  Illinois. 


35th  Michigan. 
10th  Ohio. 

3d  Connecticut. 
302d  New  York. 
15th  Minnesota. 
203d  New  York. 


2d  Georgia. 


9th  Illinois. 

2d  Virginia. 
4^th  Iowa. 
1st  Alabama. 
2d  Alabama. 
1st  Louisiana. 
2d  Louisiana. 


First  Army  Corps,  Chickamauga  Park. 


1st  Pennsylvania. 
5th  Pennsylvania. 
12th  Minnesota. 
1st  Georgia. 


Second  Army  Corps,  Camp  Alger,  Va. 

2d  Tennessee. 
8th  Pennsylvania. 


Second  Army  Corps,  Cam,p  Meade,  Pa. 

2d  West  Virginia. 
5th  Massachusetts. 
201st  New  York. 
1st  Delaware. 
4th  New  Jersey. 


Fourth  Army  Corjis,  Mobile,  Ala.,  etc. 

I      5th  Ohio. 

Seventh  Army  Corps,  Jacksonville,  Fla. 

1st  Texas. 
2d  Texas. 

1st  South  Carolina. 
161st  Indiana. 
2d  Mississippi. 
6th  Missouri. 
2d  South  Carolina. 


{h)  Thirty  additional  regiments  developed  typhoid  fever  within  14 
days  after  reaching  the  national  encampments.  In  other  words,  71, 
or  66.98  per  cent,  of  the  106  regiments  had  developed  typhoid  fever 
within  14  days  after  reaching  the  national  encampments. 

(c)  Eighty-six,  or  82.26  per  cent,  of  the  106  regiments  had  devel- 
oped typhoid  fever  within  3  weeks  after  arriving  at  the  national 
encampments. 

{d)  Five  additional  regiments  developed  typhoid  fever  within  28 
days  after  reaching  national  encampments,  thus  making  the  total 
number  of  regiments  with  typhoid  fever  28  days  after  arrival  91,  or 
85.84  per  cent. 


172 

(e)  Thirteen  additional  regiments  developed  typhoid  fever  within 
8  weeks  (viz,  5  in  5  weeks,  3  in  6  weeks,  4  in  7  weeks,  and  1  in  8 
weeks)  after  reaching  the  national  encampments,  thus  making  the 
total  number  of  regiments  with  typhoid  8  weeks  after  arrival  104,  or 
98.11  per  cent. 

Of  the  remaining  2  regiments,  1,  the  Ninth  Ohio  Battalion,  devel- 
oped typhoid  fever  in  9  weeks,  and  1,  the  First  Maryland,  in  10  weeks 
after  arrival  at  national  encampments. 

We  have  been  compelled  to  satisfy  ourselves  with  a  general  state- 
ment that  many  of  the  regiments  assembled  at  State  encampments  in 
April.  In  fact,  this  general  statement  must  suffice,  because  no  one 
day  can  be  given  as  the  day  of  assembly.  Some  companies  reached 
the  State  encampment  a  few  days  earlier  or  later  than  others.  How- 
ever, as  the  first  call  for  troops  was  issued  April  20,  1898,  it  must  fol- 
low that  all  regiments  which  assembled  at  State  encampments  in  the 
month  of  April  did  so  during  the  last  week  of  that  month.  Bearing 
this  in  mind,  and  accepting  our  cases  of  probable  typhoid  as  the  first 
cases  of  this  disease,  it  will  be  seen  by  an  inspection  of  the  table  given 
that  of  the  106  regiments  for  which  we  have  the  data  bearing  upon 
this  subject  97,  or  91.52  per  cent,  developed  tj^phoid  fever  mthin  8 
weeks  after  assembling  at  the  State  encampment. 

(3)  Typhoid  fever  developed  also  in  certain  of  the  regular  regiments 
ivithin  three  {3)  to  five  (S)  weehs  after  going  into  camp. 

When  war  with  Spain  was  proclaimed  the  total  strength  of  the 
standing  Army  of  the  United  States  numbered  27,000  of&cers  and 
men.  They  were  scattered  at  about  100  military  garrisons.  All  of 
these  soldiers  were  well  housed  and  their  quarters  were,  from  a  sani- 
tary standpoint,  in  good  condition.  At  most  of  the  garrisons,  at 
least  the  water  supply  was  above  suspicion,  and  the  disposal  of  waste 
was  such  as  not  to  endanger  health  or  the  life  of  the  soldier.  There 
was  no  epidemic  at  any  post,  and  the  army  was  reasonably  free  from 
infectious  disease,  except  those  of  venereal  origin.  The  number  of 
cases  of  typhoid  fever  among  the  27,000  officers  and  men  during  the 
first  four  months  of  1898  was  distributed  as  follows:  In  January,  9 
cases,  with  1  death;  in  February,  3  cases,  with  1  death;  in  March, 
4  cases,  with  no  deaths;  in  April,  6  cases,  with  1  death.  During 
the  last  week  in  April  and  the  first  week  of  May,  1898,  the  regular 
regiments  were  assembled  at  national  encampments  and  placed  under 
canvas.  These  regiments  were  receiving  recruits  in  considerable 
numbers  from  the  larger  centers  of  population. 

The  following  table  shows  the  dates  of  going  into  encampment  and 
the  appearance  of  first  cases  of  recognized  tj^phoid  fever  in  those  regu- 
lar regiments  for  which  we  have  been  able  to  obtain  desired  data. 


173 


Command. 


Date  of  going 
into  encamp- 
ment. 


Date  of  first 
case  of  rec- 
ognized ty- 
phoid fever. 


2d   U. 

4th  U. 

6th  U. 

7th  U. 
13th  U. 
10th  U. 
226.  U. 
24th  U. 
25th  U. 


S.  Infantry 

S.  Infantry 

S. Infantry 

S.  Infantry 

P. Infantry  .._ 

S.  Infantry 

S.  Infantry 

S.  Infantry  (colored). 
S.  Infantry  (colored) . 


Apr.  22, 1898 

do 

do 

Apr.  24, 1898 
Apr.  23, 1898 
Apr  22, 1898 

do. 

Apr.  20,1898 
do 


May  28,1898 
May  18, 1898 
May  19, 1898 
May  26, 1898 
May  8,1898 
May  20, 1898 
May  29, 1898 
May  28, 1898 
do 


(4)  Typhoid  fever  became  epidemic  both  in  the  small  encam,pm,ents  of 
not  m.ore  than  one  regiment  and  in  the  larger  ones  consisting  of  one  or 
more  corps. 

The  statement  has  been  made  that  the  epidemics  of  typhoid  fever 
in  our  national  encampments  in  1898  were  due  to  crowding  together 
large  numbers  of  men.  We  have  seen  that  the  Third  North  Carolina, 
at  its  isolated  post  at  Fort  Macon,  N.  C,  developed  typhoid  fever 
before  it  was  sent  to  Knoxville,  where  it  became  a  part  of  the  Second 
Division  of  the  First  Army  Corps. 

When  we  reached  Knoxville,  Tenn.,  in  our  round  of  inspecting  the 
troops,  we  were  informed  that  the  Fourth  Tennessee  was  encamped 
near  Knoxville,  where  it  had  been  since  mobilization,  and  that  it  was 
wholly  free  from  typhoid  fever.  A  personal  investigation  showed  the 
following  facts :  This  regiment  assembled  at  the  camp  near  Knoxville, 
Tenn.,  June  28,  1898,  although  it  was  not  mustered  into  the  United 
States  service  until  about  the  middle  of  July.  On  August  12  Ernest 
Martin,  who  had  not  been  well  for  a  week  preceding  this  time,  was 
admitted  to  the  regimental  hospital.  On  August  15  he  was  furloughed 
home,  and  on  September  11  he  died  at  his  home  in  Nashville,  Tenn., 
of  typhoid  fever.  From  the  date  of  this  first  case  up  to  the  time  of 
our  inspection  (September  14,  1898)  there  had  been  in  this  regiment 
not  less  than  11  well-marked  cases  of  typhoid  fever,  although  none 
had  been  so  diagnosed  by  the  regimental  surgeon. 

The  Fifteenth  Minnesota,  at  its  regimental  encampment  on  the  fair 
grounds  at  St.  Paul,  Minn.,  and  the  Thirty-fifth  Michigan,  at  Island 
Lake,  Michigan,  developed  epidemics  of  typhoid  fever.  Other 
instances  might  be  cited,  but  these  suffice  to  show  the  truth  of  the 
statement  that  the  disease  became  epidemic  in  small  as  well  as  in 
large  encampments. 

{5)  Typhoid  fever  became  epidemic  in  camps  located  in  the  Northern 
as  ivell  as  in  those  located  in  the  Southern  States. 

Some  Army  medical  officers  have  placed  stress  upon  the  fact  that 
Northern  men  were  transferred  to  Southern  States,  and  have  attrib- 
uted considerable  importance  to  the  influence  of  nonacclimatization 
in  the  production  of  the  epidemics  of  typhoid  fever.  In  answer  to 
this  we  need  only  call  attention  to  the  fact  that  the  Fifteenth  Min- 
nesota, Thirty-fifth  Michigan,  and  the  Two  hundred  and  third  New 


174 

York  surpassed  any  other  three  regiments  in  the  number  of  cases  of 
typhoid  fever  before  they  crossed  the  Mason  and  Dixon  line.  There 
is  nothing  more  certain  than  that  the  prevalence  of  typhoid  fever 
among  the  troops  in  1898  was  not  due  to  geographical  location. 

(6)  Typhoid  fever  is  so  luidely  distributed  in  this  country  that  one 
or  more  cases  are  likely  to  appear  in  any  regiment  tuithin  eight  weeks 
after  assembly. 

We  have  no  reliable  data  concerning  the  extent  to  which  typhoid 
fever  prevails  in  this  country,  but  from  the  number  of  deaths  from 
this  disease  we  can  fairly  estimate  the  number  of  eases.  The  follow- 
ing figures  may  give  us  some  idea  as  to  the  chances  of  infected  men 
being  found  in  each  volunteer  regiment.  In  making  this  calculation 
we  will  figure  on  the  number  of  cases  of  typhoid  fever  in  New  York 
City.  This  place  is  selected  because  it  is  not  subject  to  epidemics  of 
typhoid  fever  and,  in  fact,  is  believed  to  be  unusually  free  from  that 
disease.  In  1897  there  were  299  deaths  from  typhoid  fever  reported 
in  New  York  City.  Supposing  that  typhoid  fever  is  no  more  deadly 
in  New  York  Citj^  than  it  is  in  Hamburg — and  there  is  no  reason  for 
believing  that  it  is — then  299  (the  number  of  deaths  from  typhoid 
fever)  is  about  7.5  per  cent  of  the  total  number  of  cases  of  typhoid 
fever  that  occurred  in  New  York  City  in  the  year  given.  On  making 
this  computation  we  find  that  there  were  in  New  York  City  in  1897, 
3,853  cases  of  typhoid  fever.  It  is  safe  to  say  that  at  least  four-fifths 
of  the  cases  of  typhoid  fever  occur  in  individuals  of  the  military  age 
(between  18  and  45  years).  This  means  that  in  1897  there  were  in  New 
York  City  3,082  cases  of  typhoid  fever  among  those  inhabitants  who 
were  from  18  to  45  years  of  age.  The  Government  census  for  1890  places 
the  population  of  New  York  City  at  that  time  at  1,515,301.  A  police 
census,  made  in  April,  1895,  indicated  a  population  of  1,849,866.  We 
will  be  liberal  in  our  calculations  and  suppose  that  the  population  of 
New  York  City  in  1897  was  2,000,000.  In  round  numbers  the  number 
of  people  between  18  and  45  years  of  age  is  one-half  the  total  popula- 
tion. On  this  basis  the  number  of  people  of  military  age  in  New  York 
City  in  1897  may  be  placed  at  1,000,000.  (This  of  course  includes 
both  males  and  females. )  Had  this  1,000,000  of  people  of  military  age 
been  divided  into  regiments  of  1,300  each  they  would  have  furnished 
769  commands.  We  have  seen  that  the  number  of  cases  of  typhoid 
fever  in  New  York  City  in  1897  among  people  of  military  age  was  3,082, 
and  if  these  had  been  evenlj^  divided  among  the  regiments  of  1,300, 
each  command  would  have  contained  at  least  4  persons  who  would 
develop  typhoid  fever  during  the  year.  We  make  no  claim  that  the 
above  given  figures  are  accurate.  We  have  presented  them  simply 
for  the  purpose  of  showing  the  chances  of  there  being  men  infected 
with  tj^phoid  fever  in  every  regiment  of  volunteers.  We  think  that 
it  must  be  admitted  that  there  is  not  much  difficulty  in  accounting  for 
the  origin  of  typhoid  fever  in  our  national  encampments.     With  this 


175 

disease  as  prevalent  as  it  is  throughout  the  country,  it  is  more  than 
probable  that  in  any  organization  of  1,300  men  of  military  age  taken 
from  private  life  anrl  held  together  for  two  months  one  or  more  cases 
will  develop. 

(7)  Typhoid  fever  usually  appears  in  'military  expeditions  within 
eight  iveeks  after  assembly. 

The  following  quotations  taken  from  a  paper  on  "Enteric  fever  in 
campaigns, "  by  Surgeon-Captain  Davies,  assistant  professor  of  hygiene 
at  the  English  Army  Medical  School,  illustrate  the  above  statement: 

In  the  Galeaka-Gaika  war  in  South  Africa  the  troops  crossed  the  river  Kei  in 
December,  1877,  in  the  hot  and  dry  season.  Diarrhea  and  simple  continued  fever 
soon  became  prevalent,  but  the  general  health  was  good.  In  the  middle  of  Jan- 
uary, 1878,  heavy  rains  came  on.  In  February,  sickness  increased,  consisting  prin- 
cipallyof  diarrhea,  dysentery,  and  "common  continued  fever."  Bowel  complaints 
toward  the  end  of  March,  but  as  the  cold  season  came  on,  enteric  fever,  at  first 
mild  and  insidious,  occurred  throughout  the  country,  and  in  May  it  is  reported 
that  no  place  was  free  from  it. 

In  the  Zulu  war,  which  commenced  at  the  end  of  December,  1878,  fever  appeared 
at  the  headquarters  of  Helpmakaar,  and  at  Rorkes  Drift  in  the  middle  of  February, 
accompanied  by  diarrhea  and  dysentery;  the  fever  was  thought  to  be  "bilious 
remittent,"  "enteric, "or  a  mixture  of  both.  Helpmakaar  became  so  unhealthy 
that  the  troops  had  to  be  moved  to  Utrecht  and  Dundee.  Epidemics  of  enteric 
fever  immediately  broke  out  at  both  of  these  places. 

In  the  Afghan  campaign  of  1878-1880  it  is  noted  that  cases  occurred  at  almost 
all  the  stations  occupied  by  European  troops,  stretching  from  the  Indian  frontier 
to  Kabul  and  Kandahar.  Some  of  these  posts  had  probably  never  been  occupied 
before,  and  many  of  these  cases  were  quite  isolated. 

In  the  Egyptian  expedition  of  1882  there  was  great  prevalence  of  bowel  com- 
plaints from  the  first  landing  of  the  troops  in  the  latter  part  of  July — diarrhea. 
dysentery,  and  fever.  Enteric  fever  occurred  very  soon,  both  at  Alexandria  and 
at  Ismailia.  When  the  troops  arrived  at  Cairo  the  disease  increased  gradually, 
but  did  not  reach  any  great  prevalence  until  October  and  November.  During 
October,  November,  and  December,  out  of  a  total  of  319  deaths,-  no  less  than  223 
were  due  to  enteric  fever. 

In  the  Nile  campaign,  in  1884-85,  a  great  number  of  isolated  posts  were  occupied, 
extending  over  a  large  tract  of  country.  Enteric  fever  occurred  at  all  or  nearly 
all  of  these  posts,  most  severely  at  Assuan  and  Wady  Haifa. 

During  the  French  operations  in  Tunis  in  1881  the  disease  was  extremely  preva- 
lent, about  one-fifth  of  the  whole  force  being  attacked.  It  has  been  stated  that  all 
the  columns  on  the  march  and  nearly  every  occupied  post  were  attacked  more  or 
less.  In  some  instances  bodies  of  troops  suffered  from  the  disease  who  had  not 
been  in  contact  with  other  (infected)  troops,  and  who  had  not  occupied  any  old 
(infected)  encampments. 

We  have  brought  in  these  quotations  in  order  to  show  that  typhoid 
fever  generally,  most  probably  universally,  appears  in  militarj^  expe- 
ditions. Similar  experiences  are  recorded  in  the  histories  of  mining 
camps. 

{8)  The  miasmatic  theory  of  the  origin  of  typhoid  fever  is  not  sup- 
ported hy  our  investigations. 

There  are  still  a  few  who  believe  that  typhoid  fever  is  due  to  a  poison 
or  miasm  given  off  from  the  earth  in  gaseous  form.     We  would  not 


176 

mention  this  obsolete  theory  were  it  not  for  the  fact  that  while  in- 
specting the  camps  we  found  intelligent  medical  officers  who  believed 
that  some  intangible  local  condition  inherent  in  the  place  was  an 
important  factor  in  the  production  of  the  epidemic.  There  is  apparent 
in  man  a  tendency  to  believe  in  the  evil  genius  of  locality.  He  is 
prone  to  attribute  many  of  his  misfortunes  to  indefinable  conditions 
surrounding  the  place  in  which  he  has  suffered.  As  we  have  stated, 
no  fact  in  our  investigations  has  been  brought  out  more  prominently 
than  the  demonstration  that  locality  was  not  responsible  for  the  epi- 
demic. The  Fifteenth  Minnesota  first  developed  typhoid  fever  at  the 
fair  grounds  at  St.  Paul.  There  is  certainly  no  evidence  that  there  is 
any  evil  climatic  influence  connected  with  this  place.  It  carried  the 
epidemic  with  it  to  Fort  Snelling,  which  has  long  had  the  reputation 
of  being  one  of  the  most  healthful  army  posts  in  the  United  States, 
From  Fort  Snelling  the  Fifteenth  Minnesota  was  transferred  to  the 
open  fields  of  Camp  Meade,  where  generations  of  Pennsylvania  farm- 
ers have  passed  the  average  number  of  years  allotted  to  man  without 
suspecting  that  their  country  was  an  unhealthy  one.  However,  typhoid 
fever  continued  with  the  command  from  Minnesota  because  the  men 
carried  the  germs  of  the  disease  in  their  bodies,  clothing,  bedding, 
and  tentage.  Certainly,  any  rational  being  would  prefer  any  of  the 
above-mentioned  localities  to  Port  Tampa  as  a  place  of  summer  resi- 
dence, and  yet  there  was  not  a  regiment  in  the  Fourth  Army  Corps, 
encamped  for  so  long  a  time  in  Florida,  that  had  as  many  cases  of 
typhoid  fever  as  did  the  Fifteenth  Minnesota. 

{9)  The  pythogenic  theory  of  the  origin  of  typhoid  fener  is  not  sup- 
ported by  our  investigaUons. 

Murchison  proposed  this  theory  of  the  origin  of  typhoid  fever.  This 
author  states  the  theory  in  the  following  words : 

Typhoid  fever  may  be  generated  independently  of  a  previous  case  by  fermenta- 
tion of  fecal,  and  perhaps  other  forms  of  organic  matter. 

Translated  into  the  terms  of  modern  medicine,  this  theory  is  founded 
upon  the  belief  that  the  colon  germ  may  undergo  a  ripening  process 
by  means  of  which  its  virulence  is  so  increased  and  altered  that  it  may 
be  converted  into  the  typhoid  bacillus,  or  at  least  may  become  the  active 
agent  in  the  causation  of  typhoid  fever.  Many  French,  English  and 
American  army  medical  officers  believe  that  typhoid  fever  may  origi- 
nate in  this  way.  Rodet  and  Roux,  of  the  French  army,  have  stated 
their  belief  that  outside  of  the  body  the  colon  bacillus  acquires  "  typho- 
genic"  properties.  Surgeon-Captain  Davies,  assistant  professor  of 
hygiene  in  the  English  Army  Medical  School,  has  expressed  his  belief 
in  this  theory.  Some  of  the  medical  officers  in  the  American  Army 
have  also  given  it  their  adherence.  Surgeon  Davies  gives  the  following 
statement  of  the  reasons  for  his  belief  in  this  theory: 

It  is  well  known  that  "camp  diarrhea  "  is  of  the  commonest  occurrence  among 
troops  shortly  after  taking  the  field  in  a  tropical  or  sub-tropical  climate.     Change 


177 

of  habits,  change  of  food,  improper  or  unsuitable  food,  bad  water,  heat,  and  expo- 
sure to  sun  and  chill — these  are  all  obvious  factors  in  its  causation;  there  is  noth- 
ing in  any  way  specific.  Let  us  consider  the  sequel  as  regards  the  individual  and 
as  regards  his  surroundings.  The  individual  may  in  some  cases  remain  in  fairly 
good  health  and  vigor,  in  spite  of  a  continuance  of  the  bowel  trouble  ;  other  indi- 
viduals may  suffer  more  from  the  exposure,  fatigue,  and  weakening  effects  of  the 
continued  flux.  The  surroundings  may  possibly  be  and  remain  sanitary,  the  camp 
clean,  the  water  pure;  but  in  all  probability  the  reverse  will  be  the  case — at  any  rate, 
in  some  instances — the  water  bad.  the  soil  fouled,  very  likely  overcrowding  of  the 
camp,  with  consequent  difficulty,  if  not  impossibility,  of  proper  removal  or  disposal 
of  fecal  matters.  Under  certain  conditions  of  heat  and  moisture  favorable  to  the 
development  and  multiplication  of  low  forms  of  vegetable  and  animal  life  which 
is  the  more  likely  or  reasonable  to  expect,  that  diarrhea  in  weakly  and  exhausted 
individuals  should  remain  diarrhea  and  nothing  more,  or  that  with  an  increase 
of  filth  and  decomposition,  polluting  soil,  air,  and  water,  a  development  of  filth- 
generated,  pythogenic  poison  should  take  place,  capable  of  causing  in  such  weakly 
persons  a  fever,  with  diarrhea,  a  poisoning  of  the  organism,  producing  pyrexia 
and  inflammation  of  certain  glands  in  the  alimentary  tract —in  fact,  a  specific  fever? 
Is  this  supposition  of  the  evolution,  gradual  or  rapid  according  to  circumstances, 
of  a  disease  poison  dependent  on  increasing  conditions  of  pollution  of  soil,  air,  or 
water,  either  separately  or  all  three  together,  unreasonable  or  illogical?  Would  it 
not,  on  the  contrary,  be  more  unreasonable  to  suppose  that,  under  such  conditions, 
there  shoiild  be  no  evolution  at  all?  These  conditions  of  camp  pollution  undoubt- 
edly exist  and  tend  to  increase  in  many  instances.  Are  they  to  have  no  effect?  Is 
diarrhea  to  continue  as  simple  diarrhea,  or  is  evolution  to  come  into  action  and 
produce  a  new  disease?  New,  indeed,  only  because  the  causes  necessary  for  its  pro- 
duction are  just  now  brought  into  action^ — spontaneously  only  in  the  sense  that 
water  is  of  spontaneous  origin,  when  from  hydrogen  and  oxygen  the  electric 
spark  has  produced  water  where  no  water  was  before."' 

We  believe  that  the  results  of  our  investigations  controvert  this 
theory  conclusively.  In  the  first  place,  we  have  been  able  to  show 
that  the  specific  poison  of  typhoid  fever  was  introduced  into  every 
one  of  our  national  encampments,  and  with  the  disease  as  wide- 
spread as  it  is  in  this  country,  we  believe  that  we  have  good  reasons 
for  the  claim  that  one  or  more  men  already  specifically  infected  with 
typhoid  fever  enlisted  in  nearly  every  command.  There  is,  therefore, 
no  necessity  of  resorting  to  the  theory  that  the  colon  bacillus  may  be 
converted  into  the  tyj)hoid  bacillus.  Moreover,  all  the  known  facts 
of  experimental  bacteriology  are  at  variance  with  this  theorj^  The 
supposition  that  simple  diarrheas  may  develop  into  typhoid  fever 
will  be  again  referred  to. 

(10)  Our  investigations  confirm  the  doctrine  of  the  specific  origin  of 
typhoid  fever. 

As  has  already  been  stated,  we  have  been  able  to  trace  the  intro- 
duction of  typhoid  fever  into  every  one  of  our  national  encampments 
and  into  the  majority  of  the  regiments.  In  case  of  the  few  commands 
about  which  there  is  some  uncertainty  as  to  the  men  bringing  the 
typhoid  infection  from  their  homes,  we  may  state  that  in  all  of  these 
there  was  ample  opportunity  for  the  introduction  of  the  specific 
poison  from  other  commands. 
7273 12 


178 

{11)  With  typhoid  fever  as  widely  disseminated  as  it  isin  this  coun- 
try the  chances  are  that  if  a  regiment  of  1,S00  men  should  he  assembled 
in  any  section  and  kept  in  a  camp,  the  sanitary  conditions  of  which 
were  perfect,  1  or  more  cases  of  typhoid  fever  ivould  develop. 

We  have  already  stated  our  reasons  for  our  belief  in  the  above- 
given  proposition.     In  such  a  camp,  however,  the  disease  would  not 
I  become  epidemic  and  ultimately  it  should  disappear  altogether, 
^plf    {12)  Typhoid  fever  is  disseminated  hy  the  transference  of  the  excre- 
"     tions  of  an  infected  individual  to  the  alimentary  canals  of  others. 

It  is  more  than  probable  that  many  individuals  may  for  a  while 
carry  and  eliminate  the  specific  bacillus  of  typhoid  fever  without 
developing  the  disease  themselves.  Later  we  will  make  statements 
concerning  the  probable  proportion  of  men  who  are  immune  to  this 
disease.  In  discussing  the  etiology  of  typhoid  fever  we  have  seen  that 
persons  who  have  recovered  from  this  disease  may  for  a  long  time 
continue  to  carry  and  excrete  the  specific  poison.  We  have  also  shown 
that  the  longevity  of  the  Eberth  bacillus  outside  of  the  body  under 
certain  conditions  is  much  greater  than  is  generally  supposed.  The 
agents  by  which  the  specific  germ  of  typhoid  fever  may  be  dissemi- 
nated have  been  enumerated  and  quite  fully  discussed  in  the  chapter 
on  etiology. 

{IS)   Typhoid  fever  is  more  likely  to  become  epidemic  in  camps  than 
in  civil  life  because  of  the  greater  difficulty  of  disposing  of  the  excre- 
■     tions  from  the  human  body. 

This  proposition  is  so  self-evident  that  it  needs  no  lengthy  argument 
to  support  it.  The  influence  of  the  introduction  of  sewers  into  cities 
in  decreasing  sickness  from  this  disease  is  well  known  to  every  stu- 
dent of  sanitar}'^  science.  Moreover,  since  the  disease  is  disseminated 
by  the  transference  of  the  excretions  of  an  infected  individual  to  the 
alimentary  canal  of  others,  it  must  follow  that  the  more  thoroughly 
and  completely  the  excretions  are  removed  from  the  vicinity  of  habi- 
tations the  less  will  be  the  danger  of  infecting  the  inhabitants.  In 
fact,  the  whole  question  of  the  prevention  of  typhoid  fever  in  armies 
is  largely  one  of  the  disposition  of  the  excretions.  Later  we  will  give 
figures  to  show  that  the  prevalence  of  typhoid  fever  in  certain  camps 
was  in  an  inverse  direct  proportion  to  the  thoroughness  with  which  the 
excretions  were  removed  from  the  vicinity  of  the  camps. 
>  {IJf)  A  man  infected  with  typhoid  fe.ver  tnay  scatter  the  infection  in 
every  latrine  in  a  regiment  before  the  disease  is  recognized  in  himself. 

The  elimination  of  typhoid  bacilli  from  the  bowels  probably  begins 
soon  after  infection.  If  this  be  true,  during  the  entire  period  of  incu- 
bation an  individual  may  be  a  source  of  danger  to  others.  Moreover, 
in  most  instances  of  typhoid  fever  the  disease  is  not  recognized  during 
the  prodromal  stage,  and  during  this  time  the  excretions  may  be  laden 
with  typhoid  bacilli.  It  must  be  evident  from  this  that  the  only  way 
in  which  typhoid  epidemics  can  be  with  certainty  prevented  in  armies 


V 


179 

is  by  the  complete  disinfection  of  the  stools  of  all,  both  the  sick  and 
the  well. 

{15)  Camp  pollution  was  the  greatest  sin  coniTnitted  by  the  troops  in 
1898. 

In  our  histories  of  the  different  regiments  we  have  had  too  frequent 
opportunity  to  call  attention  to  the  fearful  pollution  that  existed  in 
many  camps.  As  we  have  already  stated,  fecal  matter  was  deposited 
on  the  surface  about  the  camps  at  Chickamauga.  Much  of  this  filth 
must  have  been  specifically  infected  with  typhoid  fever.  Sinks  were 
frequently  overflowed  by  heavy  rains,  and  their  contents  were  distrib- 
uted on  the  adjoining  surface.  It  is  needless  to  dwell  upon  this  point 
and  we  may  refer  those  who  desire  particulars  to  the  regimental  his- 
tories that  have  already  been  given. 

[16)  Some  commands  were  umvisely  located. 

AVhile  there  is  no  evidence  that  any  of  the  places  selected  for 
national  encampments  were  called  unhealthful,  it  is  true  that  some 
of  them  were  not  suited  for  camp  sites.  It  is  quite  impossible  to 
keep  camps  in  a  sanitary  condition  at  a  location  such  as  that  for 
a  while  occupied  by  one  brigade  of  the  Fourth  Army  Corps  near  Port 
Tampa,  Fla.  On  account  of  the  nature  of  the  ground  and  the  sur- 
roundings, Palmetto  Beach  was  certainly  a  very  unsuitable  location 
for  a  permanent  camp.  Every  medical  officer  in  the  First  Division 
of  the  Seventh  Army  Corps  condemned  Miami,  and  this  condemnation 
was  approved  b}^  officers  both  of  the  staff  and  of  the  line  who  visited 
this  encampment.  The  men  could  not  be  made  comfortable  at  this 
place.  Notwithstanding  these  facts  there  were  regiments  at  Chicka- 
mauga that  had  more  cases  of  typhoid  fever  than  did  any  of  them  in 
the  division  at  Miami,  but  this  is  no  reason  M^hy  the  troops  at  the 
latter  place  should  have  been  so  uncomfortably  situated.  Some  com- 
mands were  unwisely  located  for  the  simple  reason  that  the  soldiers 
could  not  be  comfortably  accommodated  at  the  places  named.  There 
was,  however,  a  much  more  serious  defect  in  the  location  of  certain 
commands.  Some  regiments  at  Chickamauga,  as  we  have  shown, 
were  so  located  that  they  received  the  drainage  of  other  regimental 
camps.     I'here  was  certainly  no  sufficient  excuse  for  this. 

(17)  In  some  instances  the  space  allotted  the  regiments  was  inade- 
quate. 

This  was  true  of  more  than  one  command  at  Chickamauga.  For 
instance,  the  One  hundred  and  fiftj^-eighth  Indiana  was  forced  to 
contract  its  lines  to  half  the  regulation  distance,  and  then  it  was  only 
30  feet  distant  from  the  Sixth  Ohio.  The  sinks  of  the  last-mentioned 
regiment  and  the  kitchens  of  the  First  West  Virginia  were  only  12  qr 
15  feet  apart.  At  Camp  Alger  the  Eighth,  Twelfth,  and  Thirteenth 
Pennsylvania  were  packed  closely  together,  with  scarcely  an  interval 
between  the  regiments;  tents  of  the  same  companies  in  contact  with 
each  other  on  the  sides,  and  of  adjacent  companies  in  contact  by  the 


u 


180 

ends.  We  are  forced  to  conclude  from  this  and  numerous  other  sim- 
ilar examples  that  there  were  line  officers  whose  efficiency  might  have 
been  enhanced  by  some  knowledge  of  camp  hygiene. 

{18)  Many  commands  luere  allowed  to  remain  on  one  site  too  long. 

There  were  regiments  at  Chickamauga  that  did  not  move  a  tent 
from  the  time  of  arrival  in  May  to  that  of  departure  late  in  August. 

{19)  Requests  for  change  in  location  made  by  medical  officers  icere 
not  ahvays  granted. 

As  an  illustration  under  this  head  we  may  call  attention  to  the 
official  records  of  the  Fifth  Pennsylvania.  This  command  reached 
Chickamauga  Park  May  20,  and  it  was  unfortunately  located  on  low 
ground.  Requests  for  a  change  in  location  were  repeatedly  sent  in 
during  June  and  July.  The  soil  became  muddy,  the  camp  received 
the  washings  from  other  camps  above,  the  sinks  rapidly  filled  with 
water  and  overflowed,  and  still  requests  for  change  in  location 
were  unheeded  until  August  12,  when  the  regiment  was  allowed  to 
occupy  a  new  camp  two  miles  to  the  west  and  on  a  higher  piece  of 
ground. 

{20)  Superior  line  officers  can  not  he  held  altogether  blameless  for  tlie 
unsanitary  condition  of  the  camps. 

As  we  have  already  seen,  some  of  the  regiments  were  improperly 
located  from  a  sanitary  standpoint.  This  was  done  by  superior  line 
officers,  and  sometimes  in  the  face  of  protests  from  the  medical  offi- 
cers. We  have  also  seen  that  requests  for  change  in  location  were 
disregarded,  and  regiments  were  allowed  to  occupy  one  site  for  too 
long  a  time.  In  general,  the  camps  became  very  filthy.  It  must 
therefore  be  admitted,  it  appears  to  us,  that  line  officers  were  to  some 
extent  responsible  for  the  condition  of  the  camps  under  their  com- 
mand. The  medical  officer  can  onlj'  recommend;  the  line  officer  can 
command.  We  think  it  unfortunate  that  hygiene  is  not  taught  in 
our  national  military  school.  It  does  seem  that  line  officers  should 
be  able  to  recognize  the  importance  of  reasonable  requests  and  recom- 
mendations made  by  the  medical  officers. 

{21)  Grreater  authority  should  be  given  medical  officers  in  questions 
relating  to  the  hygiene  of  camps. 

In  our  opinion  it  is  of  the  greatest  importance  that  more  authority 
be  granted  medical  officers  in  all  matters  pertaining  to  the  hygiene  of 
camps. 

(  {22)  It  may  be  stated  in  a  genercd  way  that  the  number  of  cases  of 
typhoid  fever  in  the  different  camps  varied  with  the  methods  of  dispos- 
ing of  the  excretions. 

This  is  well  illustrated  by  the  methods  of  disposing  of  fecal  matter 
and  the  number  of  cases  of  typhoid  fever  in  the  three  divisions  of  the 
Seventh  Arm}^  Corps.  The  First  Division  was  most  uncomfortably 
located  at  Miami,  Fla. ,  from  the  last  week  in  June  until  the  second  week 
in  August.     On  the  last-mentioned  date  it  was  removed  to  Jackson- 


181 

ville,  where  it  joined  the  other  divisions.  During  a  part  of  its  stay 
at  Miami,  and  during  the  entire  period  of  its  encampment  at  Jack- 
sonville, water  carriage  was  employed  for  the  disposition  of  fecal 
matter.  The  number  of  cases  of  probable  typhoid  fever  that  devel- 
oped in  the  six  regiments  of  this  division  was  1,030.  In  the  Second 
Division  the  tub  system  of  disposing  of  fecal  matter  was  employed. 
By  this  method  infected  fecal  matter  was  scattered  all  through  the 
camp.  The  number  of  cases  of  probable  typhoid  fever  that  devel- 
oped in  nine  regiments  of  this  division  was  2,693.  In  the  Third 
Division  regulation  pits  were  used  for  the  disposal  of  fecal  matter. 
The  number  of  cases  of  probable  typhoid  fever  that  developed  in 
seven  regiments  of  this  division  was  1,292. 

{23)  The  tub  system  of  disposal  of  fecal  matter  as  practiced  in  the 
Second  Division  of  the  Seventh  Army  Corps  is  to  he  condem,ned. 

Of  all  the  methods  used  for  the  disposal  of  fecal  matter  practiced 
in  the  national  encampments  in  1898,  this  we  regard  as  the  most 
unsatisfactory.  The  reason  for  our  condemnation  of  this  system  has 
already  been  given. 

{2J})  The  regulation  pit  system  is  not  a  satisfactory  method  of  dis- 
posing of  fecal  matter  in  permanent  camps. 

.  Especially  is  this  true  in  tropical  countries,  and  in  temperate 
climates  during  the  summer  time.  It  is  a  very  difficult  thing  to  have 
the  soldiers  appreciate  the  necessity  of  keeping  fecal  matter  covered. 
As  we  have  elsewhere  stated,  in  many  camps  orders  were  issued 
requiring  each  man  to  cover  his  feces  as  soon  as  deposited ;  but  we  did 
not  inspect  the  pits  of  a  regiment  in  which  we  did  not  find  exposed 
fecal  matter.  Moreover,  in  our  camps  in  1898  flies  swarmed  so  numer- 
ously that  the  first  droppings  of  fecal  matter  were  often  covered  with 
them  before  the  act  of  defecation  was  completed.  The  pit  system  may 
be  employed  when  armies  are  on  the  march  and  stopping  at  one  place 
for  a  few  days  at  most,  but  even  then  they  are  sources  of  danger,  and 
we  believe  that  it  is  quite  impossible  to  wholly  prevent  the  spread  of 
typhoid  fever  in  camps  in  which  this  method  of  disposing  of  fecal 
7uatter  is  employed.  We  have  seeu  how  difficult  it  was  to  prepare 
sinks  of  proper  dimensions  at  Chickamauga,  and,  furthermore,  that 
it  was  quite  impossible  to  keep  the  contents  of  these  sinks  properly 
covered.  The  clay  thrown  out  in  digging  the  pits  hardened  in  the 
sun  and  when  thrown  back  into  the  pit  on  the  fecal  matter  had  but 
little  absorptive  power,  and  the  result  was  that  fecal  matter  was  con- 
stantly exposed.  We  have  also  seen  that  in  some  of  the  camps  about 
Tampa  it  was  impossible  to  dig  sinks  on  account  of  the  height  of  the 
ground  water.  For  these  reasons  we  are  thoroughly  convinced  that  if 
epidemics  of  typhoid  fever  are  to  be  prevented  some  other  method  of 
<iisposing  of  fecal  matter  in  camps  occupied  for  a  week  or  longer  must 
l^e  resorted  to. 

{25)  In  permanent  canqjs  tvhere  water  carriage  can  not  he  secured 


182 

all  fecal  matter  should  he  disinfected  and  then  carted  away  from  the 
camp. 

For  this  purpose  we  liave  made  a  special  recommendation  that 
galvanized-iron  troughs  containing  milk  of  lime  be  used  for  the 
reception  of  all  fecal  matter  and  urine,  and  that  the  contents  of  these 
troughs  be  removed  daily  by  means  of  the  portable  odorless  excavator. 
We  are  aware  of  the  fact  that  this  method  of  disposing  of  fecal  matter 
will  be  attended  by  increased  cost,  but  we  are  confident  that  it  will 
lessen  greatly  the  number  of  cases  of  typhoid  fever.  We  believe  that 
there  is  no  question  pertaining  to  army  hj^giene  of  more  importance 
than  that  relating  to  the  method  of  disposing  of  fecal  matter  and 
urine.  The  way  in  which  this  is  done  will  largelj'^  determine  the 
number  of  cases  of  typhoid  fever  that  will  develop  in  any  command. 
We  feel,  therefore,  that  we  can  not  be  too  urgent  in  our  recommenda- 
tion of  the  abolition  of  former  methods  of  disposing  of  fecal  matter 
and  the  adoption  of  some  other  system  of  disinfecting  all  excreta. 
This  system  has  been  adopted  by  the  War  Department,  and  a  full 
description  published  in  General  Orders,  No.  170,  Adjutant-General's 
/^Office,  Washington,  September  26,  1899. 

[26)  Infected  'water  was  not  an  important  factor  in  the  spread  of 
typhoid  fever  in  the  national  encampments  in  1898. 

There  were  probably  local  water  supplies  that  became  specifically 
infected  with  the  typhoid  fever  bacillus,  but  infected  water  was  not 
the  great  factor  in  the  causation  of  this  disease.  It  is  possible  that 
the  piped  water  at  Chickamauga  became  specifically  contaminated. 
Certainly,  the  location  of  the  intake  pipe  in  Chickamauga  Creek  so 
near  the  junction  of  that  stream  with  the  Cave  Spring  Branch  which 
drained  many  of  the  camps  was  not  justifiable,  and  it  hardly  seems 
possible  that  the  piped  water  wholly  escaped  contamination.  How- 
ever, that  even  at  Chickamauga  infected  water  was  not  the  chief 
factor  in  the  spread  of  typhoid  fever  is  shown  by  the  fact  that  regi- 
ments which  did  not  drink  piped  water  also  became  widely  infected 
with  the  disease,  and  it  is  furthermore  demonstrated  by  the  fact  that 
the  spread  of  typhoid  fever  continued  after  the  regiments  had  been 
moved  to  Knoxville,  Tenn.,  and  Lexington,  Ky.,  at  both  of  which 
places  the  water  supply  was  above  suspicion.  It  is  also  probable  that 
some  of  the  local  water  supplies  at  Chickamauga  became  specifically 
contaminated.  This  might  have  been  true  of  the  wells  from  which 
the  regiments  of  the  Second  Division  of  the  First  Army  Corps  for 
a  while  drew  their  water  supply.  The  location  of  Jay's  Mill  well,  for 
instance,  was  such  as  to  receive  the  drainage  from  typhoid  fever 
infected  camps  near  it,  and  it  is  not  likely  that  this  water  escaped 
specific  contamination.  We  are  also  inclined  to  attribute  the  greater 
prevalence  of  typhoid  fever  in  the  Third  Army  Corps  to  the  fact  that 
the  sites  covered  by  the  regiments  of  this  corps  furnished  many  wet- 
weather  springs,  which  in  all  probability  were  contaminated.     That 


183 

the  water  was  not  infected  at  Jacksonville  seems  to  be  beyond  ques- 
tion. This  supply  came  from  artesian  wells  more  than  1,000  feet 
deep,  and  was  distributed  throug;h  the  camps  by  means  of  pipes.  In 
August  and  September  of  1898  there  were  in  round  numbers  at  Jack- 
sonville 30,000  civilians  or  inhabitants  of  the  city  and  the  same  num- 
ber of  soldiers  encamped  near  by.  Both  civilians  and  soldiers  drank 
water  from  the  same  source.  There  were  only  a  few  sporadic  cases 
of  tj^phoid  fever  in  the  city  at  a  time  when  each  of  the  three  division 
hospitals  was  receiving  a  score  or  more  of  patients  with  this  disease 
each  day.  The  same  condition  existed  at  Knoxville.  Here  the  sol- 
diers obtained  their  water  supplj^  from  the  pipes  that  furnished  West 
Knoxville.  We  satisfied  ourselves  from  an  inspection  of  the  health 
officer's  books  that  there  were  no  cases  of  typhoid  fever  among  the 
citizens  at  that  time,  and  still  there  were  hundreds  of  cases  among 
the  soldiers. 

At  Camp  Alger  certain  local  water  supplies  probably  became  con- 
taminated, but  there  is  no  evidence  that  this  was  generally  true. 
Each  regiment  obtained  its  supply  from  a  bored  well,  and  while  there 
was  some  question  about  the  wisdom  of  the  location  of  a  few  of  these, 
the  majority  were  so  situated  and  so  constructed  that  infection  seemed 
well-nigh  impossible.  The  same  is  true  of  the  water  supply  at  Camp 
Meade. 

(27)  To  guard  against  the  conto.'mination  of  the  ivater  supply,  troops 
in  the  field  shoidd  he  provided  with  means  for  the  sterilization  of  ivater. 

Our  investigations  of  the  methods  of  sterilization  and  cooling  water 
have  been  given  elsewhere.  (See  Report  of  the  Surgeon-General  of  the 
Army,  1899,  pp.  215-225.) 

{28)  Flies  'Undoubtedly  served  as  carriers  of  the  infection. 

Flies  swarmed  over  infected  fecal  matter  in  the  pits  and  then  visited 
and  fed  upon  the  food  prepared  for  the  soldiers  at  the  mess  tents.  In 
some  instances  where  lime  had  recently  been  sprinkled  over  the  con- 
tents of  the  pits,  flies  with  their  feet  whitened  with  lime  were  seen 
walking  over  the  food. 

It  is  possible  for  the  fly  to  carry  the  typhoid  bacillus  in  two  ways. 
In  the  first  place,  fecal  matter  containing  the  typhoid  germ  may 
adhere  to  the  fly  and  be  mechanically  transported.  In  the  second 
place,  it  is  possible  that  the  typhoid  bacillus  may  be  carried  in  the 
digestive  organs  of  the  fly  and  be  deposited  with  its  excrement. 

{29)  It  is  more  than  likely  that  men  transported  infected  material  on 
their  persons  or  in  their  clothing  and  thus  disseminated  the  disease. 

We  have  condemned  the  method  which  was  followed  in  many  of 
the  camps  of  detailing  men  from  the  ranks  to  act  as  orderlies  at  the 
hospitals.  In  some  of  the  commands  it  was  customary  to  detail  100 
or  more  men  from  the  line  every  morning.  These  men  went  to  the 
hospitals,  handled  bed  pans  used  by  persons  sick  with  typhoid  fever, 
and  at  night  returned  to  their  comrades.     The  most  of  these  men  were 


184 

wliolly  ignorant  of  the  nature  of  infection  and  the  methods  of  disin- 
fection. In  fact,  at  one  of  the  division  hospitals  we  saw  orderlies  of 
this  kind  go  from  the  hospital  and  partake  of  their  midday  meal  with- 
out even  washing  their  hands.  These  men  handled  not  only  the  food 
which  they  ate,  but  passed  articles  to  their  neighbors.  It  seems  to  us 
that  a  more  certain  method  for  the  dissemination  of  an  infectious 
disease  could  hardly  have  been  invented. 

We  have  stated  that  in  some  of  the  camps  the  surface,  especially 
where  there  were  strips  of  wood,  was  frequently  dotted  with  fecal 
deposits.  At  the  time  of  our  inspection  of  the  Third  U.  S.  Volunteer 
Cavalrj^  at  Chickamauga  it  was  quite  impossible  to  walk  through  the 
woods  near  the  camp  without  soiling  one's  feet  with  fecal  matter. 
Much  of  this  was  probably  specificallj"  infected,  and  it  is  bj^no  means 
improbable  that  the  infection  was  carried  by  the  men  into  their  tents, 
where  blankets  and  tentage  became  infected. 

{30)  Typhoid  fever,  as  it  developed  in  the  regimented,  organizations, 
was  characterized  hy  a  series  of  company  epidemics,  each  one  having 
more  or  less  perfectly  its  oiun  individual  characteristics. 

The  truth  of  this  statement  will  be  evident  after  the  inspection  of 
the  charts  showing  the  distribution  of  tj^phoid  fever  among  the  com- 
panies of  the  different  regiments.  On  making  such  an  inspection, 
one  must  be  impressed  with  the  fact  so  plainly  evident  there  that  men 
who  are  closeh^  associated  develop  typhoid  fever  simultaneously.  Men 
in  the  same  company  came  down  with  the  disease  on  the  same  day. 
This  is  still  more  marked  when  we  study  the  cases  with  reference  to 
the  tents  occupied  by  the  men.  Of  1,608  cases  of  typhoid  fever  which 
we  have  been  able  to  accurately  locate  in  the  particular  tents  in  which 
they  occurred,  together  with  the  date  of  commencement  of  the  attack, 
the  results  may  be  summarized  as  follows: 

Directly  connectable  attacks,  563,  or  35.01  per  cent. 

Indirectly  connectable  attacks,  447,  or  27.79  per  cent. 

Total  connectable  attacks,  1,010,  or  62.80  per  cent. 

Certain  tents  were  badly  infected  and  the  majority  of  all  their 
inmates  developed  the  disease,  while  other  tents  wholly  escaped. 
Blankets  and  tentage  became  soiled  with  typhoid  discharges  and  in 
this  way  the  disease  was  propagated  and  carried  by  the  company 
wherever  it  went.  We  believe,  therefore,  that  personal  contact  was 
a  verj^  important  factor  in  the  spread  of  the  disease. 

{31)  It  is  probable  that  the  infection  ivas  disseminated  to  some  extent 
through  the  air  in  the  form  of  dust. 

The  shell  roads  through  the  encampment  at  Jacksonville  were 
ground  into  the  finest  dnst  by  the  heavy  army  wagons.  The  scaven- 
ger carts  carrying  the  tubs  filled  with  fecal  matter  passed  along  these 
roads  and  their  course  could  often  be  traced  by  bits  of  feces  falling 
from  the  tubs.  Other  vehicles  ground  up  the  fecal  matter  and  dust 
together  and  the  winds  disseminated  these  particles  here  and  there. 


185 

Men  inhaled  this  dust.  It  was  deposited  on  food  in  the  mess  tents 
by  the  roadside,  and  men  ate  the  dust.  Pollution  of  the  soil  with  the 
urine  of  those  suffering  with  typhoid  fever  was  of  frequent  occur- 
rence. Cases  of  this  disease  under  the  diagnosis  of  malarial  fever 
were  repeatedly  treated  by  the  regimental  surgeon  throughout  the 
entire  sickness.  Patients  still  convalescing  were  also  returned  to 
their  respective  companies.  Under  these  conditions  there  must  have 
been  abundant  opportunity  for  contamination  of  the  camp  site  with 
the  specific  germ.  We  are  therefore  inclined  to  the  opinion  that 
infected  dust  was  one  of  the  factors  in  the  dissemination  of  typhoid 
fever. 

(32)  A  command  badly  infected  with  typhoid  fever  does  not  lose  the 
infection  by  simply  changing  location. 

We  do  not  mean  to  say  that  it  is  not  advantageous  for  a  regiment 
badly  infected  with  typhoid  fever  to  change  its  location.  On  the 
other  hand,  in  our  history  of  the  Second  Division  of  the  First  Army 
Corps  we  have  shown  that  such  change  is  of  advantage  and  may  be 
followed  by  a  reduction  in  tlie  number  of  cases ;  but  mere  change  in 
location  is  not  sufficient  to  stamp  out  the  disease  in  a  command  after  it 
has  become  widely  disseminated.  The  histories  of  many  regiments 
show  this  to  be  true.  The  Second  Division  of  the  First  Army  Corps 
became  badly  infected  with  typhoid  fever  at  Chickamauga ;  later  it 
moved  to  Knoxville,  Tenn.  At  the  latter  place  the  location  was  an 
ideal  one.  The  water  supply  was  above  suspicion ;  the  surface  gentlj^ 
rolling  and  the  natural  drainage  good.  The  soil  was  deep,  and  pits  of 
proper  depths  were  easily  constructed.  Soil  thrown  out  in  digging  the 
pits  dried  in  the  sun  and  became  highly  absorptive,  so  that  when  thrown 
back  upon  the  fecal  matter  it  took  up  the  moisture  readily.  Notwith- 
standing all  these  favorable  conditions  typhoid  fever  continued,  and 
Instead  of  showing  the  slightest  abatement  increased  in  prevalence. 
The  regiments  that  went  from  Chickamauga  to  Lexington,  Ky.,  had 
a  similar  experience,  although  it  is  not  so  marked  in  these,  because 
they  had  been  more  severely  affected  at  Chickamauga,  and  a  larger 
proportion  of  the  susceptible  material  had  been  used  up.  The  regi- 
ments of  the  First  Division  of  the  First  Army  Corps  that  went  to 
Porto  Rico  carried  the  infection  along  with  them  but  with  little  if 
any  abatement.  Numerous  other  illustrations  equally  striking  might 
be  given. 

|(;-  {3S)  When  a  command  badly  infected  with  typhoid  /ever  changes 
its  location  it  carries  the  specific  agents  of  the  disease  in  the  bodies  of 
the  men,  in  their  clothing,  bedding,  and  tentage. 

This  is  shown  by  the  fact  that  when  commands  changed  location, 
leaving  behind  them  all  their  sick,  and  when  they  went  to  places  free 
from  the  infection  the  disease  continued  with  them, 

{34)  Even  an  ocean  voyage  does  not  relieve  an  infected  command  of 
its  infection. 


186 

This  is  shown  to  be  the  case  in  the  study  of  the  various  commands 
that  went  to  Cuba  and  Porto  Rico.  The  regiments  constituting  the 
Fifth  Armj-  Corps,  that  went  from  Tampa  to  Santiago  in  June,  were 
not  widely  infected  before  embarkation,  and  some  of  them  were  on 
board  ship  for  sixteen  days  and  yet  all  developed  one  or  more  cases 
either  on  the  way  or  soon  after  reaching  Cuba.  The  regiments  that 
went  from  Chickamauga  were  widely  infected  before  leaving  this 
country,  and  the  disease  continued  after  their  landing  with  but  little 
if  any  abatement. 

(35)  After  a  command  becomes  badly  infected  with  typhoid  fever 
changes  of  location,  together  ivith  thorough  disinfection  of  cdl  clothing y 
bedding,  and  teniage  is  necessary. 

Even  when  disinfection  is  carried  out,  as  here  suggested,  the  com- 
mand will  not  altogether  lose  its  typhoid  infection,  because  some  of 
the  men  will  carry  the  germs  of  the  disease  in  their  bodies.  Change 
of  location  removes  the  command  from  the  infected  locality;  disin- 
fection of  clothing,  bedding,  and  tentage  destroys  the  infected  mate- 
rial deposited  upon  these  articles,  but  the  germs  that  have  already 
been  introduced  into  the  bodies  of  men  are  not  so  easily  reached. 
The  utility  of  disinfection  of  clothing,  bedding,  and  tentage  was 
demonstrated  by  Colonel  Girard,  who  carried  out  this  procedure  in 
some  of  the  most  seriously  infected  regiments  at  Camp  Meade  with 
very  gratifying  results. 

{86)  Except  in  case  of  the  most  urgent  military  necessity  one  com- 
mand should  not  be  located  upon  the  site  recently  vaccded  by  another. 

This  principle  holds  good  even  when  the  vacating  regiment  is  not 
known  to  have  suffered  from  any  infectious  disease.  This  axiom  in 
military  hygiene  was  frequently  violated  during  the  summer  of  1898. 
In  many  of  the  State  encampments  the  regiments  that  responded  to 
the  second  call  were  located  on  sites  recently  vacated  by  commands 
that  had  proceeded  to  the  national  encampments.  This  was  true  of 
the  Fifteenth  Minnesota,  the  Thirty-fifth  Michigan,  and  the  Two  hun- 
dred and  third  New  York,  each  of  which  had  as  many  cases  of  typhoid 
fever  as  any  one  of  the  regiments  in  the  great  national  encampments. 
The  Third  Illinois  at  Chickamauga  was  located  upon  ground  which 
had  recently  been  vacated  by  the  Sixteenth  U.  S.  Infantry.  The  reg- 
ular regiment  had  occupied  this  site  only  eight  daj^s,  and  during  this 
time  had  reported  no  sickness,  but  soon  after  it  reached  Tampa  it 
developed  13  cases  of  acute  intestinal  catarrh,  3  cases  of  diarrhea,  and 
3  cases  of  typhoid  fever.  When  the  Second  Brigade  of  the  First  Divi- 
sion of  the  First  Army  Corps  reached  Chickamauga  Park,  the  site 
selected  for  the  regimental  camp  of  the  Third  Illinois  occupied  a  part 
of  that  recently  vacated  by  the  Sixteenth  U.  S.  Infantry,  while  the 
other  regiments  of  this  brigade  were  i)laced  some  distance  away.  This 
brigade  remained  at  Chickamauga  until  July  22,  during  which  time 


187 

the  Third  Illinois  developed  60  cases  of  typhoid,  the  Fourth  Pennsyl- 
vania 26  cases,  and  the  Fourth  Ohio  19  cases.  Additional  instances 
of  this  kind  have  been  given  in  the  body  of  our  report. 

{S7)  The  fact  that  a  command  expects  to  change  its  location  does  not 
justify  neglect  of  proper  policing  of  the  ground  occupied. 

The  filthy  condition  of  many  of  the  regimental  camps  at  Chicka- 
mauga  was  explained  on  the  ground  that  each  regiment  expected  to 
be  called  to  the  front  in  a  few  days  and  therefore  neglected  camj) 
sanitation.  It  is  needless  for  us  to  say  that  the  explanation  does  not 
justify  the  neglect.  A  camp  site  should  be  thoroughly  policed  up  to 
the  moment  of  vacating  it.  This  should  be  insisted  upon  as  a  matter 
of  military  discipline,  and  camp  commanders  should  regard  proper 
attention  to  the  sanitation  of  the  site  occupied  by  their  troops  as  one 
of  their  highest  duties  and  the  neglect  as  a  crime. 

{38)  It  is  desirable  that  the  soldier^s  bed  should  be  raised  from  the- 
ground. 

In  some  of  the  regiments  at  Camp  Alger  the  tents  were  never  floored. 
On  inspecting  these  commands  in  August  we  found  dust  several  inches 
deep  in  the  tents.  During  the  daytime,  in  fair  weather,  the  blankets 
were  taken  out,  and  men,  possibly  with  their  feet  soiled  with  infected 
material,  walked  around  in.  the  dust  and  at  night  threw  the  blankets 
down  on  it  and  there  slept.  At  other  encampments  flooring  was  pur- 
chased with  regimental  funds.  We  admired  the  enterprise  of  the  men 
in  some  regiments  who  built  in  their  tents  a  scaffold  of  poles,  covered 
this  with  straw,  and  made  their  beds  on  this.  We  can  not  but  think 
that  sleeping  in  a  dust  pile,  which  was  possibly  infected  with  tj^phoid 
stools,  was  not  wise. 

(39)  In  some  of  the  encampments  the  tents  were  too  much  crotvded. 

This  was  true  both  of  the  space  allowed  for  the  tents  and  of  the 
number  of  men  occupying  each  tent.  In  some  instances  the  tents  of 
the  same  company  were  so  close  together  as  to  leave  no  space  between 
them,  and  those  of  two  adjacent  companies  were  crowded  together 
back  to  back.  Inasmuch  as  none  of  these  commands  were  in  the 
vicinity  of  any  hostile  camp,  this  overcrowding  seems  to  have  been 
wholly  unnecessary.  Medical  officers  should  vigorouslj^  remonstrate 
against  arrangements  of  this  kind.  In  some  of  the  commands  at 
Chickamauga  the  tents  were  not  shifted,  but  stood  continuously  on. 
the  one  spot  where  they  were  pitched  in  Ma}^  until  the  command  left 
late  in  August. 

{4-0)  Medical  officers  should  insist  that  soldiers  remove  their  outer 
clothing  at  night  when  the  exigencies  of  the  situation  permit. 

With  from  12  to  16  men  in  a  tent,  all  sleeping  in  their  clothes  worn 
during  the  day,  and  possibly  with  some  of  them  soiled  with  infected 
fecal  material,  the  effect  upon  the  general  health  certainly  could  not 
be  beneficial,  and  the  possibility  of  the  dissemination  of  infection 


188 

must  be  admitted.  If  privates  in  the  ranks  would  give  more  atten- 
tion to  personal  cleanliness,  and  if  they  were  furnished  with  quarters 
in  which  they  could  keep  themselves  clean,  typhoid  fever  and  other 
infectious  diseases  among  troops  in  the  field  would  be  greatly 
decreased.  Our  investigations  show  that  tent  infection  must  have 
been  an  important  factor  in  the  distribution  of  typhoid  fever. 

(^i)  Malaria  icas  not  a  'prevalent  disease  among  the  troops  thai 
remained  in  tJie  United  States. 

We  have  shown  in  the  body  of  this  report  that  blood  examinations 
for  the  Plasmodium  of  malaria  made  by  competent  men  at  Camp 
Alger,  Chickamauga,  Knoxville,  Camp  Meade,  and  Jacksonville  show 
that  malaria  was  a  very  rare  disease  among  the  troops  that  remained 
in  the  United  States.  This  disease  was  undoubted^  more  common 
in  some  of  the  camps  than  the  blood  examinations  would  indicate, 
l3ecause  these  were  made  for  the  most  part  on  hospital  patients  and 
not  upon  those  who  merely  reported  to  the  regimental  surgeon,  were 
given  quinine,  and  returned  to  duty  in  a  day  or  two.  The  malaria 
that  did  exist  in  the  national  encampments  in  this  country  yielded 
readily  to  quinine,  and  the  cases  that  did  not  jdeld  to  this  treatment 
were  not  malarial.  It  is  unfortunate  for  scientific  medicine  that  a 
competent  man,  properly  equipped  for  making  blood  examinations, 
was  not  stationed  at  each  division  hospital  at  the  time  of  its  organiza- 
tion. Certainly  we  have  a  right  to  expect  that  the  Government  aa^U 
use  the  best  and  the  most  scientific  methods  in  its  Army  medical 
service.  Had  this  been  done  scientific  medicine  would  have  been 
enriched  by  contributions  of  the  greatest  value.  Is  it  too  much  to 
ask  that  a  division  hospital  be  furnished  with  facilities  for  scientific 
diagnosis  equivalent  to  those  possessed  by  all  first-class  hospitals? 

(4^)  Hie  continued,  fever  that  prevailed  among  the  soldiers  in,  this 
country  in  1898  was  typhoid  fever. 

There  is  no  evidence  that  anj'  other  continued  fever  was  found 
among  the  troops  that  remained  in  the  United  States.  AVe  have  men- 
tioned the  claim  of  one  surgeon  that  dengue  prevailed  in  his  regiment 
-at  Chickamauga.  We  think  it  quite  impossible  for  dengue  to  have 
prevailed  in  one  regiment  while  all  other  troops  of  two  army  corps 
encamped  at  the  same  place  escaped  this  disease.  It  was  claimed  by 
some  that  the  continued  fever  prevalent  at  Chickamauga  differed 
from  tj^hoid  fever,  and  that  it  was  a  disease  peculiar  to  the  place,  and 
it  was  designated  as  ' '  Chickamauga  fever. "  That  the  continued  fever 
preA-alent  in  our  camps  in  1898  was  typhoid  fever  is  demonstrated  by 
the  following  facts : 

(a)  When  the  temperature  curve  was  not  vitiated  by  the  use  of 
antipyretics  it  was  that  of  tj^pical  typhoid  fever. 

(b)  The  fever  was  not  broken  or  arrested  by  the  administration  of 
quinine. 


189 

(c)  The  death  rate  was  that  of  typhoid  fever. 

{d)  Whenever  a  post-mortem  examination  was  made,  and  the  total 
of  these  examinations  was  considerable,  the  characteristic  lesions  of 
typhoid  fever  were  found. 

{43)  In  addition  to  the  recognized  cases  of  typhoid  fever,  there  were 
many  short  or  abortive  attacks  of  this  disease  which  were  generally 
diagnosed  as  some  form  of  malarial  fever. 

While  entertaining  the  opinion  that  many  of  the  short  febrile  attacks 
were  due  to  errors  in  diet,  as  our  own  investigations  proceeded  we 
strongly  inclined  to  the  belief  that  a  considerable  proportion  of  these 
fevers  of  short  duration  were  due  to  infection  with  the  tj^phoid  bacil- 
lus, and  hence  were  to  be  considered  as  cases  of  mild  or  abortive 
typhoid  fever.  In  other  parts  of  this  report  we  have  called  attention 
to  the  coincident  rise  and  fall  of  these  supposed  malarial  fevers  with 
the  occurrence  of  recognized  typhoid  fever  in  certain  companies  and 
regiments.  Our  studies  have  shown  that  those  soldiers  who  had 
recovered  from  these  suj^posed  nialarial  fevers  of  short  duration 
afterwards  possessed  a  relatively  marked  immunit}^  against  typhoid 
fever,  as  comj^ared  with  those  who  had  not  suffered  with  these  milder 
fevers.  The  following  table  will  give  the  result  of  our  investigation 
bearing  on  this  point  in  forty-eight  regiments  of  the  Second  and  Sev- 
enth Army  Corps. 

Table  showing ,  f 07^  forty-eight  regiments  of  the  Second  and  Seventh  Army- Corj^s, 
the  cases  of  typhoid  fever  among  men  with  or  without  preceding  malarial  diseases. 


Num- 
ber of 
regi- 
ments. 

Mean 
strength. 

Cases 

Typhoid  fever 

with  preceding 

malaria. 

Men  in 
regi- 
ments 

Typhoid  fever 
without  preced- 
ing malaria. 

Total 

Camp. 

of 
mala- 
ria. 

Num- 
ber of 
cases. 

In  100 
mala- 
rial 
cases. 

not 
having 
had 
mala- 
ria. 

Num- 
ber of 
cases. 

In  100  in- 
divid- 
uals who 
had  no 
malaria. 

of  ty- 
phoid 
fever. 

Alger 

.Jacksonville 

Meade 

19 

7 
13 

31,988 
7,990 
1.5, 093 
10, 759 

4,083 
3,366 
1,430 
1,676 

63 

46 

72 
81 

Per  CI. 
1.5 
1.9 
5.0 

4.8 

17,905 
5,634 

13,663 
9,083 

1,888 
1,246 
2,305 
3,044 

Per  cent. 
10.5 
22.1 
16.9 
23.5 

1,951 

1,392 
2,377 

Jacksonville _ . 

Total.. 

9 

3,125 

48 

55,839 

9,555 

263 

2.7 

46,274 

7,483 

16.1 

7,745 

Thus,  in  a  mean  strength  of  55,829  men,  there  were  9,555  who  had 
experienced  attacks  of  fever,  which  was  generally  designated  as  some 
form  of  malarial  disease,  most  frequently  as  malarial  remittent  fever 
Of  this  number  only  262,  or  2.7  per  cent,  suffered  from  subsequent 
attacks  of  typhoid  fever.  On  the  other  hand,  of  46,274  men  who 
did  not  experience  any  attack  of  supposed  malarial  fever,  7,483,  or 
16.1  per  cent,  contracted  typhoid  fever. 

{JfJf)  Wliile  our  examinations  show  that  coincident  infection  with 
malaria  and  typhoid  fever  may  occur,  the  resulting  coviplex  of  symp- 


190 

io7)is  are  not  sufficiently  luell  defined  and  uniform  to  be  recognized  as  a 
separate  disease. 

We  have  in  the  body  of  this  report  devoted  a  special  chapter  to  this 
subject,  to  which  those  desiring  detailed  information  are  referred. 

(^5)  About  one-fifth  of  the  soldiers  in  the  national  encampments  in 
the  United  States  in  1898  developed  typhoid  fever. 

Among  107,973  of&cers  and  men  in  92  regiments,  the  records  of  which 
we  have  carefully  studied,  the  number  of  cases  of  typhoid  fever, 
according  to  our  estimate,  was  20,738.  This  is  equivalent  to  19.26 
per  cent. 

{Jf6)  Army  surgeons  correctly  diagnosed  about  half  the  cases  of 
typhoid  fever . 

The  total  number  of  probable  cases  of  typhoid  fever  among  the  92 
regiments  studied  was  20,738.  Of  these  10,428,  or  50.27  per  cent, 
were  diagnosed  as  typhoid  fever  either  by  regimental  or  hospital  sur- 
geons. Most  of  the  cases  improperly  diagnosed  were  sent  to  general 
military  hospitals  or  to  civil  hospitals  with  the  diagnosis  of  malaria. 
In  80  out  of  85  cases  sent  from  the  Fifth  Maryland  to  civil  hospitals 
in  Baltimore,  the  diagnosis  was  changed  from  malaria  to  typhoid 
fever.  Out  of  98  cases  sent  from  the  Eighth  New  York  to  hospitals 
in  New  York  City  on  September  9,  all  were  recognized  as  typhoid 
fever  by  the  physicians  in  charge  of  the  hospital,  while  the  majority 
of  these  cases  had  been  entered  on  the  sick  reports  under  other  diag- 
noses. Of  101  cases  of  fever  transferred  to  the  hospitals  at  Hartford 
and  New  Britain,  Conn.,  by  the  First  Connecticut  Infantry,  on  its 
departure  from  Camp  Alger,  Va.,  September  7,  1898,  98  received  the 
diagnosis  of  tyi)hoid  fever,  and  only  3  the  diagnosis  of  malaria.  The 
failure  of  the  regimental  surgeon  to  properly  diagnose  many  cases  of 
typhoid  fever  is  easily  explained.  Orders  required,  very  properly, 
that  every  man  sick  for  forty-eight  hours  should  be  sent  to  the  divi- 
sion hospital.  It  will  be  seen  from  this  that  the  cases  were  not  under 
the  observation  of  the  regimental  surgeon  for  a  sufficient  time  for  him 
to  make  a  diagnosis.  There  is  also  some  excuse  for  the  failure  of  the 
surgeons  at  the  division  hospitals  to  recognize  all  cases  of  typhoid 
fever.  Many  of  the  less  severe  of  these  cases  remained  in  hospital 
for  a  short  time  and  were  furloughed  home  or  forwarded  to  some  gen- 
eral hospital.  Moreover,  we  have  shown  in  the  body  of  our  report 
that  in  recognizing  nearly  half  the  cases  of  typhoid  fever  the  army 
surgeon  probably  did  better  than  the  average  physician  throughout 
the  countrj^  does  in  his  private  practice. 

{Jf7)   The  percentage  of  death  among  cases  of  typhoid  fever  was  7.61. 

Of  the  20,738  cases  already  mentioned  as  occurring  in  92  regiments, 
1,580  died.  This  gives  a  death  rate  of  7.61  per  cent.  This  corre- 
sponds closely  with  the  death  rate  for  typhoid  fever  in  those  places  in 
which  most  accurate  records  have  been  kept.     In  the  city  of  Hamburg 


191 

during  the  years  1886  and  1887  there  were  10,823  cases,  with  a  death 
rate  of  8.5  per  cent.  In  1897  there  were  1,885  cases  at  Maidstone, 
England,  with  a  death  rate  of  7.5.  Brandt  has  collected  19,017  cases 
treated  by  cold  baths,  with  a  mortality  of  7.6  per  cent.  Of  2,293  cases 
treated  in  some  of  the  larger  hospitals  in  this  country  in  1807,  9.24 
per  cent  died. 

{4-8)  When  a  command  is  thoroughly  saturated  with  typhoid  fever  it 
is  prohahle  that  one-fourth  to  one-third,  of  the  men  ivill  he  found  suscep- 
tible to  this  disease. 

We  are  inclined  to  the  opinion,  but  desire  to  state  it  only  as  an 
opinion,  that  typhoid  fever  disappeared  in  some  of  the  regiments  only 
after  all  the  susceptible  material  had  been  exhausted.  This  was 
probablj'^  true  in  all  regiments  which  had  400  or  more  cases. 

{Jf.9)  In  military  practice  typhoid  fever  is  often  apparently  an  inter- 
mittent disease. 

We  have  stated  that  typhoid  fever  is  often  apparently  an  intermit- 
tent disease.  We  do  not  mean  that  the  apparent  intermissions  are 
afebrile;  we  only  mean  that  the  men  sick  with  this  disease  had  periods 
of  improvement,  and  these  were  so  marked  that  regimental  surgeons 
sometimes  returned  to  duty,  probably  at  the  request  of  the  men,  those 
who  were  sick  with  typhoid  fever. 

{50)  The  belief  that  errors  in  diet  with  consequent  gastric  and  intes- 
tinal catarrh  induce  typhoid  fever  is  not  supported  by  our  investigaiions. 

This  belief,  which  was  formerly  held  hj  many,  is  founded  upon  false 
conclusions  arising  from  erroneous  conceptions  of  the  etiology  of  the 
disease.  Moreover,  the  early  sjauptoms  of  typhoid  fever  are  often 
confounded  with  those  of  simple  gastro-intestinal  catarrh. 

{51)  The  belief  that  simple  gastro-intestinal  disturbances  predispose 
to  typhoid  fever  is  not  supported  by  our  investigations. 

As  has  been  elsewhere  stated,  the  menibers  of  this  board  began  their 
investigations  with  the  belief,  which  seems  to  be  quite  generally  held, 
that  acute  diseases  of  the  gastro-intestinal  tract  render  the  individual 
more  susceptible  to  subsequent  infection  with  tyi3hoid  fever.  How- 
ever; our  studies  have  forced  us  to  come  to  the  following  conclusions 
concerning  the  relations  between  tj^phoid  fever  and  preceding  tem- 
porary disorders,  including  those  diagnosed  as  diarrhea,  enteritis, 
gastro-enteritis,  gastro-duodenitis,  intestinal  catarrh,  gastro-intestinal 
catarrh,  gastric  fever,  and  simple  indigestion : 

(a)  The  temporary  gastro-intestinal  disturbances  of  May  and  June 
had  little  if  any  effect  upon  subsequent  infection  with  typhoid  fever. 

(6)  The  temporarygastro-intestinaldisturbances  of  July  and  August, 
instead  of  predisposing  to  typhoid  fever,  gave  a  certain  degree  of 


192 


immunity  against  subsequent  infection  with  this  disease, 
tigations  may  be  summarized  as  follows : 


Our  inves- 


Tdble  showing  for  forty-eight  regiments  of  the  Second  and  Seventh  Covins  cases  of 
typhoid  fever  among  men  with  or  ivithout  preceding  diarrheal  diseases. 


Diarrheal 
diseases. 

Cases  of  diar- 
rheal diseases 

followed  by 
typhoid  fever. 

Num- 
ber of 
men 
who 
had  no 
preced- 
ing 
diar- 
rhea. 

Typhoid  fever 
without  pre- 
ceding diarrheal 
diseases. 

Total 

Camp. 

her  of       Mean 

regi-     strength, 
ments.                        Num- 
ber of 
cases. 

Num- 
Ijer  of 
indi- 
vid- 
uals. 

Num- 
ber of 
cases. 

In  100 
men 
with 
preced- 
ing 
diar- 
rhea. 

Num- 
ber of 
cases. 

In  100 
individ- 
uals who 
had  no 
diarrhea. 

cases 
of  ty- 
phoid 
fever. 

Alger 

Jacksonville 

Meade 

Jacksonville 

Total  — . 

19          21,988      3,a54 
7            7,990  I    2,370 

1.3          15,092      2.048 
9          10,759  1    2,056 

3,894 
1,877 
],857 
1,8.53 

174 
131 
179 
164 

4.4 
6.9 
9.1 

8.8 

18,094 
6,113 

13,235 
8,906 

1,777 
1.161 
2,198 
1,961 

9.8 
18.9 
16.6 
22.2 

1,951 

1,292 
3,377 
2,125 

48  i       55,829  ,  11,828 

'                    1 

9,481 

648 

6.8 

46,348 

7,097 

15.3 

7,745 

It  will  be  seen  that  of  9,481  men  who  had  previous  diarrheal  attacks, 
648,  or  6.8  per  cent,  contracted  tj^phoid  fever;  whereas  of  46,348  sol- 
diers who  had  no  preceding  diarrhea,  7,097,  or  15.3  i)er  cent,  developed 
tj^hoid  fever. 

{52)  In  a  considerable  per  cent  (a  litfle  more  than  one-third)  of  tJie 
cases  of  typhoid  fever  which  are  recorded  as  having  been  preceded  by 
some  intestinal  disturbance,  the  preceding  illness  teas  so  closely  fol- 
loiued  by  typhoid  fever  thcd  we  must  regard  the  former  as  having 
occurred  ivithin  the  period  of  incubation  of  the  Icdier. 

For  particulars  on  this  point  see  the  chapter  on  etiology. 
-     {53)  More  than  90  per  cent  of  the  men  tuho  developed  typhoid  fever 
had  no  preceding  intestinal  disorder. 

In  7,745  cases  in  which  this  point  was  especially  investigated  7,097 
(91.63  per  cent)  Avere  not  preceded  by  any  intestinal  disorder. 

{5Ji)  The  deaths  from  typhoid  fever  were  86. 2 J^  per  cent  of  the  toted 
deaths. 

{55)  The  morbidity  from  typhoid  fever  per  1,000  of  mean  strQngth 
was  a  little  less  than  one-fifth  {192.65). 

The  highest  morbidity  was  in  the  case  of  the  Forty-ninth  Iowa 
Infantry,  and  the  lowest  in  the  Second  Pennsylvania  Infantry,  a  regi- 
ment which  never  reached  a  national  encampment. 

{56)  The  mortality  from  typhoid  fever  per  1,000  of  mean  strength 
was  lJf.63. 


193 

The  following  table  contains  data  illustrating  these  points: 


Num- 
ber of 
regi- 
ments. 

Mean 
strength. 

Cases  of  typhoid 
fever. 

Deaths 

from 

typhoid 

fever. 

Deaths 
from  all 

diseases. 

Command,  etc. 

Certain. 

Certain 
and 
proba- 
ble. 

First  Army  Corps  (Chickamauga) 

Third  Army  Corps  (Chickamauga). 

Fourth  Army  Corps  (Chickamauga) 

Second  Army  Corps  (Algerj     

22 
17 
7 
18 
12 

9 

27,380 
20,568 
7,507 
19,807 
13,962 

10, 759 

2,912 
1,741 
440 
1,807 
1,799 

1,739 

5,921 
4,418 
1,498 
2.226 
2,690 

2,693 

344 
417 
99 
212 
150 

248 

397 
469 
112 
259 

168 

Seventh  Army  Corps,  Second  Division 
(Jacksonville)  

281 

Total ,.. _ 

85 
7 

99, 9&3 
7,990 

10,428 

19,446 
1,292 

1,460 
120 

1  686 

Seventh  Army  Corps,  Third  Division.  _. 

146 

Grand  total 

92 

107,973 

20, 738 

1,580            1  .<*.'?2 

Num- 
ber of 
regi- 
ments. 

Deaths  from 
typhoid  fever 
in  100  cases. 

Per- 
cent- 
age of 
deaths 
from 
ty- 
phoid 

to 
deaths 
from 
all  dis- 
eases. 

Morbidity  of 

typhoid  fever 

in  1,000  mean 

strength. 

1 

Deaths 

Command,  etc. 

Cer- 
tain ty- 
phoid. 

Cer- 
tain 
and 
proba- 
ble 
type. 

For 
certain 
cases 
of  ty- 
phoid. 

For 
certain 

and 
proba- 
ble 
cases 
of  ty- 
phoid. 

from 
typhoid 
in  1,000  of 

mean 
strengrth. 

First  Army  Corps  (Chickamauga) 

Third  Army  Corps  (Chickamauga) 

Fourth  Army  Corps  (Chickamauga) 

.'^pcnnrt   Army  f~!nT-ps  (Alger) 

23 
17 
7 
18 
13 

9 

11.46 
23.95 
32.50 
11.73 
8.33 

14.34 

5.64 
9.43 
6.60 
9.53 
5.57 

9.20 

84.13 
88.91 
88.39 
81.87 
89.28 

88.25 

106.35 
84.64 
58.61 
91.23 

128.84 

160. 70 

316.25 
314.  79 
199.  .54 
113. 38 
193.67 

350.30 

12.19 

30.27 
13.17 

10  70 

Second  Army  Cor ps  ( Meade ) 

Seventh  Army  Corps,  Second  Division 
(Jacksonville)  -- 

10.74 
23  05 

Total         

85 
7 

14.00 

7.50 
9.28 

86.59 
82.19 

104. 29 

194.  49 
161. 70 

14  60 

Seventh  Army  Corps,  Third  Division.. _ 

15.01 

Grand  total 

92 

7.60 

86.24 

192.65 

It  63 

{57)   Tlie  average  ijeriod  of  incubation  in  typhoid  fever  it>  probably 
about  ten  and  a  half  days. 

Our  data  are  not  sufficient  to  enable  us  to  make  any  positive  deduc- 
tion on  this  point,  but  from  a  careful  study  of  780  cases  of  typhoid 
fever  in  which  the  period  of  incubation  was  based  upon  the  average 
interval  between  connectable  typhoid  attacks  in  tents  or  between 
diarrheal  and  typhoidal  attacks  in  the  same  individual  this  was 
found  to  be  10.4  days.  The  shortest  period  of  incubation  would 
appear  to  be  slightly  less  than  8  days. 
7273 13 


194 
CHAPTER  XV. 

THE  ETIOLOGY  OF  TYPHOID  FEVER. 

THE    BACILLUS. 

Typhoid  fever  is  caused  by  a  specific  micro-organism,  generally 
known,  from  its  discoverer,  as  the  Eberth  bacillus.  This  bacterium 
finds  its  way  with  food  and  drink  through  the  mouth  and  stomach  into 
the  small  intestines,  where  it  develops,  produces  specific  lesions,  and 
elaborates  chemical  poisons  which  induce  the  characteristic  symptoms 
of  the  disease.  In  addition  to  its  location  in  the  walls  of  the  intes- 
tines, this  germ  is  usually  found  after  death  from  this  disease  in  the 
mesenteric  glands  and  in  the  spleen.  If  proper  bacteriological  exam- 
ination be  made  directlj^  after  death,  the  bacillus  is  usually  found  in 
pure  culture  in  these  organs.  For  this  reason  the  spleen  is  generally 
selected  for  bacteriological  study  and  for  the  preparation  of  cultures 
after  death  from  typhoid  fever.  However,  it  seems  to  be  possible  for 
this  bacillus  to  reach  any  part  of  the  body  and  to  find  lodgment  in 
various  tissues,  ha\dng  been  found  in  the  lungs,  liver,  kidneys,  bones, 
muscles,  and  brain.  Its  lodgment  in  diverse  parts  of  the.body  and 
its  long-continued  existence  in  these  localities  are  accountable  for 
many  of  the  varied  sequelae  to  typhoid  fever. 

Typhoid  fever  may  run  its  course  and  terminate  fatally  without 
causing  the  intestinal  ulceration,  generally  regarded  as  the  specific 
lesion  of  this  disease.  More  than  20  cases  of  death  from  this  disease 
in  which  j)Ost-mortem  examination  has  failed  to  show  intestinal  ulcer- 
ation have  alreadj'  been  recorded,  and  it  is  probable  that  this  number 
will  be  increased  by  future  observations.  It  must  be  evident  from 
the  existence  of  these  eases  that  the  bacillus  may  penetrate  the  intes- 
tinal wall  without  leaving  a  marked  lesion  and  that  the  elaboration 
of  its  chemical  poisons  is  not  confined  to  the  intestinal  tract.  It 
remains  for  future  investigations  to  determine  whether,  ordinarily, 
in  this  disease  the  intestinal  lesion  precedes  or  follows  the  infection 
of  the  spleen  and  mesenteric  glands.  The  existence  of  typhoid  fever 
without  intestinal  ulceration  emphasizes  the  desirability  of  a  classifi- 
cation of  diseases  based  upon  etiology  rather  than  upon  pathology. 

The  evidence  that  the  Eberth  bacillus  is  the  cause  of  typhoid  fever 
consists  of  the  following  demonstrated  facts : 

(1)  This  bacterium  is  found  in  the  spleen  of  every  person  dying  of 
typhoid  fever  when  a  projDer  bacteriological  examination  of  this  organ 
is  made. 

(2)  This  bacillus  elaborates  poisonous  substances  in  artificial  cul- 
ture media. 

(3)  The  blood  serum  of  individuals  sick  with  typhoid  fever  has  a 
specific  agglutinative  action  on  this  bacterium. 

The  fact  that  none  of  the  lower  animals,  so  far  as  we  know,  ever 
develop  typhoid  fever,  or  are  susceptible  to  this  disease,  as  it  mani- 


195 

fests  itself  in  man,  makes  it  impossible  to  obtain  the  exj)erimeutally 
conclusire  evidence  of  the  causal  relationship  of  this  germ  to  this 
disease  that  has  been  obtained  in  the  study  of  the  micro-organisms  of 
certain  other  alfections,  such  as  anthrax,  tetanus,  tuberculosis, 
glanders,  diphtheria,  and  some  other  maladies.  All  the  animals  ordi- 
narily submitted  to  experimentation  of  this  kind  have  been  inoculated 
with  this  bacillus  by  diverse  methods,  but  the  results  obtained  have 
been  inconstant  in  appearance  and  varied  in  character.  Upon  many 
animals  the  Eberth  bacillus  is  without  effect.  In  some  the  blood  has  a 
markedly  destructive  action  upon  this  germ.  In  others,  intoxication, 
which  may  result  in  death  if  the  quantity  employed  be  sufficient,  but 
without  the  characteristics  of  true  infection,  follows.  Very  rarely 
the  effect  more  nearh'  resembles  an  infection ;  but  in  none  of  the 
lower  animals  has  there  been  induced  by  inoculation  with  this  bacillus 
up  to  the  present  time  a  disease  identical,  either  clinically  or  patho- 
logically, with  tj-phoid  fever,  as  observed  in  man.  It  is  true  that  in 
some  of  the  lower  animals  after  death  resulting  from  intravenous 
inoculation  with  the  Eberth  bacillus,  there  may  be  found  swelling, 
and,  in  isolated  places,  sloughing  of  the  follicles  of  the  small  and 
large  intestines,  marked  enlargement  of  the  spleen,  cloudy  swelling 
of  the  kidnej^s,  necrosis  in  the  liver,  and  infiltration  of  the  mesenteric 
glands.  "While  these  lesions  resemble  those  of  typhoid  fever,  they 
are  by  no  means  identical  with  those  found  in  man  after  death  from 
this  disease,  nor  can  it  be  said  that  the  lesions  just  mentioned  as 
occasionally  observed  in  the  lower  animals  are  characteristic  of  the 
action  of  this  germ,  since  other  micro-organisms  induce  similar 
changes  when  introduced  into  these  animals.  Some  observers  have 
emphasized  the  fact  that  there  is  a  tendency  on  the  part  of  this 
bacillus  to  accumulate  in  the  spleen  of  animals  inoculated  intraven- 
ously or  intraperitoneally,  and  have  seen  in  this  phenomenon  an  evi- 
dence of  the  causal  relationship  of  the  Eberth  bacillus  to  t5T)hoid 
fever;  but  it  is  like%^'ise  a  fact  that  a  similar  tendency  to  collect  in 
the  spleen  is  observable  in  inoculation  experiments  with  many  other 
bacilli. 

Xot withstanding  the  great  amount  of  experimental  evidence  col- 
lected concerning  the  effects  of  this  germ  upon  the  lower  animals,  we 
are  still  in  doubt  as  to  the  extent  to  which  it  multiplies  in  the  body 
after  inoculation.  However,  we  can  state  that  in  most  of  the  lower 
animals  the  Eberth  bacillus  does  not  multiply  after  its  introduction 
by  inoculation,  or  does  so  to  a  very  limited  extent  and  for  a  very  short 
time.  It  has  been  quite  universally  observed  in  experiments  upon 
different  species  that  if  the  animal  does  not  succumb  within  two  or 
three  days  at  most,  its  recoverj'^  from  the  effects  of  the  inoculation  is 
certain.  This  indicates,  as  has  been  stated  above,  that  death  in  the 
lower  animals  following  inoculations  with  the  Eberth  bacillus  is  due 
to  the  chemical  poisons  contained  in  the  culture,  and  can  not  be  eon- 


196 

sidered  as  the  result  of  a  true  inf  ectiou.  It  should  be  understood  that 
these  statements  are  founded  upon  experiments  made  up  to  the  pres- 
ent time,  and  that  they  are  not  intended  as  prophecies.  We  know 
that  the  Eberth  bacillus  varies  quite  widely  in  virulence,  and  that  its 
action  can  be  greatly  intensified  by  repeated  passages  through  the 
bodies  of  the  lower  animals,  and  it  may  be  found  in  the  future  that 
its  infective  power  can  under  certain  conditions  be  increased  to  such 
an  extent  that  it  may  affect  the  lower  animals  similarly  to  man. 
Moreover,  it  must  be  recognized  that  experimental  inoculation  prac- 
ticed on  the  lower  animals  is  by  no  means  identical  with  infection,  as 
it  ordinarily  occurs  in  man.  Animal  experimentation  has  been  of  the 
greatest  service  in  the  study  of  the  etiology  of  this  and  other  diseases, 
but  that  the  conditions  attending  these  experiments  are  not  identical 
with  those  accompanying  natural  infection  is  e^adent  to  all.  Experi- 
ments upon  the  lower  animals  with  the  Eberth  bacillus  have  been 
made  with  pure  cultures,  a  condition  which  never  prevails  in  the  intes- 
tines of  the  man  who  develops  typhoid  fever.  The  man  who  drinks 
water  infected  with  typhoid  bacilli  takes  into  his  alimentary  canal  at 
the  same  time  other  micro-organisms.  Moreover,  the  newly  intro- 
duced bacilli  find  in  the  intestines  more  or  less  abundant  growths  of 
other  micro-organisms  which  vary  within  certain  limits  from  time  to 
time.  In  view  of  the  few  facts  that  we  know  concerning  the  influence 
of  one  bacterium  upon  the  virulence  of  another,  we  are  hardly  justified 
in  assuming  that  a  pure  culture  of  the  Eberth  bacillus  will  induce, 
either  in  man  or  in  the  lower  animals,  the  same  effects  as  those  that 
follow  infection  in  the  presence  of  other  micro-organisms. 

Notwithstanding  the  fact  that  we  have  been  unable  to  induce  typhoid 
fever  in  the  lower  animals  bj^  inoculation  with  the  Eberth  bacillus, 
we  have  still  good  reasons  for  adhering  to  the  oi)inion  that  this  micro- 
organism is  the  specific  cause  of  this  disease.  [N'umerous  competent 
observers  have  made  frequent  bacteriological  examinations  of  the 
spleens  of  those  dead  from  tyjphoid  fever,  and  in  all  cases  the  Eberth 
bacillus  has  been  detected,  generally  in  pure  culture  in  this  organ. 
It  is  true  that  this  bacillus  does  not  always  show  exactly  the  same 
tinctorial  and  cultural  characteristics,  and  that  it  is  modified  to  some 
extent  by  the  soil  upon  wkich  it  grows  and  the  conditions  under  which 
it  develops. 

Furthermore,  it  may  be  said  that  every  one  of  the  so-called  crucial 
tests  that  have  been  proposed  for  its  positive  identification  has  been 
found  to  be  fallible.  Nevertheless,  from  a  large  number  of  compara- 
tive studies  of  the  bacilli  obtained  from  the  spleen  after  death  from 
typhoid  fever,  in  epidemics  widely  separated  geographically,  we  must 
conclude  that  the  germ  invariably  found  in  this  organ  is  one  and  the 
same,  in  spite  of  certain  minor  differences.  While  the  constant 
appearance  of  this  bacillus  in  the  bodies  of  those  dead  from  typhoid 
fever  by  no  means  proves  the  organism  to  be  the  cause  of  the  disease, 


197 

it  forms  the  first  link  in  the  chain  of  evidence  necessary  to  tlie  dem- 
onstration of  this  relationship.  Certainly  if  the  bacillus  were  not 
present  in  all  cases  it  could  not  be  the  cause  of  the  disease,  and  from 
what  we  know  of  other  infectious  maladies,  the  constant  presence  of 
this  germ  in  typhoid  fever  is  strong  presumptive,  but  not  conclusive, 
evidence  that  it  is  the  cause  of  the  disease. 

The  fact  that  the  Eberth  bacillus  is  toxicogenic  is  corroborative 
evidence  of  its  causal  relationship  to  typhoid  fever.  If  the  germ  were 
not  poisonous  it  could  not  cause  the  disease.  Putting  together  the 
facts,  (1)  the  germ  is  found  in  the  body  in  all  cases  of  typhoid  fever, 
(2)  it  is  not  found  in  the  body  except  in  typhoid  fever,  (3)  it  produces 
poisons,  the  e^^ddence  that  the  Eberth  bacillus  is  the  cause  of  typhoid 
fever  falls  but  little  short  of  being  conclusive.  However,  it  must  be 
admitted  that  there  still  remains  some  ground  for  argument.  For 
instance,  it  might  be  said  that  the  elaboration  of  chemical  poisons 
bj'  a  given  micro-organism  in  artificial  culture  media  is  no  proof  that 
the  same  substances  are  produced  when  the  micro-organism  multiplies 
in  the  human  body.  On  this  point,  also,  experimental  evidence  seems 
to  be  incapable  of  bringing  us  to  an  unquestionable  conclusion. 
Granting  that  the  Eberth  bacillus  forms  the  same  poison  or  poisons 
in  the  animal  body  that  it  does  in  artificial  culture  media,  it  remains 
a  difficult  task  to  demonstrate  that  the  products  of  its  growth  are  the 
specific  poisons  of  typhoid  fever.  In  the  first  place,  it  can  hardly  be 
expected  that  the  sj'mptoms  resulting  from  the  relatively  slow  but 
long-continued  elaboration  of  a  ]3oison  within  the  body  can  be  identi- 
cal with  those  following  the  sudden  introduction  of  a  relatively  large 
amount  of  the  same  poison  into  a  healthy  animal.  In  the  second 
place,  it  is  a  well-known  fact  that  many  poisons  vary  quite  markedly 
in  their  effects  upon  different  species  of  animals.  For  these  reasons 
it  would  not  be  a  matter  of  surprise  if  we  possessed  beyond  question 
the  specific  poison  or  poisons  of  tj'phoid  fever  to  find  that  these 
would  fail  to  induce  in  the  lower  animals  a  clinical  picture  of  the 
symptoms  of  typhoid  fever  as  it  is  seen  in  man.  Therefore,  it  follows 
that,  although  neither  the  bacillus  nor  its  chemical  products  produce 
in  the  lower  animals  the  symptoms  characteristic  of  tyj)hoid  fever  in 
man,  this  micro-organism  may  still  be  the  specific  germ  and  its  prod- 
ucts the  specific  poisons  of  typhoid  fever. 

It  may  be  of  interest  to  make  a  brief  statement  concerning  our 
present  knowledge  of  the  poisonous  products  of  the  Eberth  bacillus. 
In  1885  Brieger  obtained  from  pure  cultures  of  this  germ  a  poisonous 
base  which  induces  in  guinea  pigs  an  increased  flow  of  saliva,  fre- 
quency of  respiration,  dilatation  of  the  pupils,  profuse  diarrhea,  mus- 
cular pai-alysis,  and  death  within  from  tAventj'-four  to  forty-eight 
hours.  Post-mortem  examination  of  these  animals  shows  the  heart  to 
be  in  systole,  the  lungs  liypera^raic,  and  the  intestines  contracted  and 
pale.     This  basic  substance  was  at  first  believed  to  be  the  specific 


198 

poison  of  typhoid  fever,  and  witli  this  idea  Brieger  christened  it  typho- 
toxiu;  but  more  recent  and  more  elaborate  investigation  has  shown 
that  the  poisonous  products  of  the  Eberth  bacillus  are  more  complicated 
than  is  indicated  by  the  discovery  of  this  comparatively  simple  chem- 
ical substance.  The  existence  of  a  poisonous  proteid  within  the  cells 
of  this  germ  has  been  demonstrated  hj  a  number  of  independent  inves- 
tigators. A  noteworthy  fact  in  this  connection  is  the  discovery  that 
by  means  of  repeated  relatively  small  injections  of  this  proteid  body 
animals  can  be  rendered  immune  to  virulent  cultures  of  the  bacillus. 
This  indicates  that  the  complex  proteid  contained  within  the  cell  of 
the  germ  constitutes  the  specific  poison  of  the  disease.  The  deter- 
mination of  the  chemical  constitution  of  this  body  awaits  further 
research.  It  is  within  the  range  of  possibility  that  the  chemical  poison 
to  which  the  complex  of  symptoms  characteristic  of  typhoid  fever  is 
due  may  result,  in  part,  at  least,  from  mixed  cultures  present  in  the 
intestines  of  the  individual  suif ering  from  this  disease.  From  typhoid 
stools  there  has  been  obtained  a  poisonous  substance  which,  when 
injected  hypodermically  in  dogs  or  administered  by  the  mouth,  causes 
an  elevation  of  temperature  accompanied  by  vomiting  and  purging. 
At  present  our  knowledge  concerning  the  chemistry  of  the  etiology  of 
typhoid  fever  is  general  and  vague,  and  additional  research  is  neces- 
sary before  satisfactory  statements  concerning  it  can  be  made. 

Additional  evidence  that  the  Eberth  bacillus  is  the  specific  bacte- 
rium of  typhoid  fever  is  furnished  by  observing  the  effect  of  blood 
serum  from  an  individual  sick  with  this  disease,  or  recently  recovered 
from  the  same,  upon  the  germ.  A  few  years  ago  Pfeiffer  discovered 
that  the  blood  serum  of  an  animal  which  had  been  rendered  immune 
to  a  given  germ  manifests  a  specific  and  characteristic  action  upon 
this  germ  when  both  are  introduced  into  the  body  of  a  healthy  animal. 
The  details  of  the  experiments  may  be  carried  out  as  follows : 

Render  a  guinea  pig  or  other  animal  immune  to  the  typhoid  or 
other  bacillus  by  repeated  inoculations  with  small  quantities  of  the 
bacillus.  Take  a  fraction  of  a  drop  of  the  serum  obtained  from  the 
blood  of  the  animal  thus  rendered  immune  to  the  given  germ,  add  a 
looj)  of  the  culture  of  this  germ  to  the  serum,  and  inject  the  mixture 
into  the  abdominal  cavity  of  a  healthy  guinea  pig.  After  a  short 
time  open  the  abdominal  cavity  of  this  animal  and  make  a  micro- 
scopical study  of  the  organism  which  has  been  introduced  as  above 
described.  Instead  of  opening  the  abdominal  cavity  some  of  the  peri- 
toneal exudate  may  be  removed  from  time  to  time  by  means  of  a 
sterilized  capillary  pipette.  It  will  be  found  that  the  bacterial  cells 
are  undergoing  a  characteristic  degeneration.  Almost  immediately 
after  the  injection  of  the  germ  and  serum  the  former  becomes  non- 
motile  and  later  is  converted  into  a  granular  bod^^,  which  apparently 
dissolves  in  the  surrounding  fluid.  This  phenomenon,  which  is  gen- 
erally designated  as  Pfeiffer's  reaction,  is  believed  to  be  in  the  high- 


199 

est  degree  specific.  Blood  serum  from  an  animal  rendered  immune 
to  the  cholera  vibrio  will  have  the  above-described  effect  upon  the 
cholera  bacillus  and  upon  no  other  micro-organism.  Likewise,  the 
blood  serum  of  an  animal  immune  to  typhoid  fever  is  necessary  in 
order  to  induce  these  changes  in  the  Eberth  bacillus.  It  is  generally 
believed  by  bacteriologists  that  this  reaction  is  so  certainl}^  specific 
that  it  can  be  relied  upon  in  distinguishing  one  germ  from  another 
after  all  attempts  to  do  so  by  other  means  have  failed. 

Later,  Gruber  and  Durham  discovered  that  a  specific  action  of  the 
blood  serum  of  an  animal  suffering  from  a  given  infectious  disease  or 
recently  recovering  from  the  same  upon  the  germ  of  this  disease  may 
be  observed  outside  the  body.  If  a  few  drops  of  blood  serum  from  an 
animal  which  has  been  rendered  immune  to  a  given  germ  be  mixed 
with  a  loop  of  a  growing  culture  of  this  organism  and  the  mixture  be 
examined  under  a  microscope,  it  will  soon  be  seen  that  the  bacterial 
cells  are  quite  markedly  affected  by  the  fluid  in  which  they  find  them- 
selves. The  bacilli  lose  motility  and  collect  in  clumps  or  agglutinate. 
The  very  dilute  blood  serum  from  an  immune  animal  manifests  this 
specific  action  upon  the  germ  against  which  the  immunity  has  been 
secured,  but  not  upon  any  other  micro-organism.  It  is  true  that  the 
blood  serum  from  healthy  animals  has  more  or  less  agglutinative 
action,  but  the  phenomenon  takes  place  in  high  dilutions  of  blood 
serum  only  when  the  latter  has  been  obtained  from  an  animal  ren- 
dered immune  to  the  specific  germ  under  examination.  Blood  serum 
from  an  animal  rendered  immune  to  the  cholera  bacillus  agglutinates 
this  germ,  but  is  without  effect  upon  the  typhoid  bacillus;  while,  on 
the  other  hand,  the  blood  serum  from  an  animal  rendered  immune  to 
the  Eberth  bacillus  agglutinates  this  organism  and  is  without  effect 
upon  the  cholera  vibrio  or  any  other  micro-organism.  It  will  be  seen 
from  these  statements  that  the  phenomenon  of  agglutination  is 
believed  to  be  in  the  highest  degree  specific.  Therefore,  when  Widal 
discovered  that  blood  serum  obtained  from  a  man  suffering  with  or 
recently  recovered  from  typhoid  fever  has  an  agglutinative  action 
upon  the  Eberth  bacillus  similar  to  that  observed  in  the  blood  serum 
of  animals  rendered  immune  to  this  germ,  the  evidence  of  the  causal 
relationship  of  this  micro-organism  to  typhoid  fever  was  greatly 
strengthened.  As  is  well  known,  the  Widal  test  has  been  exten- 
sively used  in  all  parts  of  the  civilized  world  as  a  means  for  the 
recognition  of  typhoid  fever,  and  its  value  has  been  quite  positively 
established.  It  should  be  stated  in  this  connection  that  the  aggluti- 
nation reaction  is,  in  man,  at  least,  a  phenomenon  of  infection  rather 
than  one  of  immunity. 

With  the  above-mentioned  evidences  before  us,  it  must  be  admitted 
that  there  is  but  little  room  left  to  doubt  that  the  Eberth  bacillus  is 
the  specific  micro-organism  of  typhoid  fever.  However,  it  must  not 
be  inferred  that  the  bacteriology  of  typhoid  fever  needs  no  further 


200 

investigation.  There  are  many  problems  yet  to  be  solved.  We  will 
refer  to  only  a  few  of  these  at  this  time.  The  distinction  between  the 
typhoid  bacillus  and  the  colon  bacterium  is  not  well  defined.  It  is 
easy  enough  to  distinguish  between  a  typical  colon  bacillus  and  a 
typical  typhoid  bacillus.  The  former  coagulates  milk,  ferments  glu- 
cose or  lactose,  and  produces  indol  by  its  growth  in  ordinary  nutrient 
media.  The  typical  typhoid  bacillus  does  none  of  the  above-men- 
tioned things,  but  there  are  germs  which  ferment  glucose  and  lactose 
more  or  less  energetically,  but  do  not  coagulate  milk  or  produce  indol. 
There  are  others  which  show  traces  of  indol  in  their  culture  growths, 
but  do  not  coagulate  milk  or  ferment  glucose.  In  other  words,  there 
are  micro-organisms  which  at  present  we  can  not  place  in  either  the 
colon  or  the  typhoid  group,  and  the  relation  of  these  to  typhoid  fever 
has  not  as  yet  been  determined.  We  are  in  the  habit  of  designating 
these  bacteria  as  typhoid-like  bacilli.  They  have  been  found  in 
water  supposed  to  be  the  cause  of  epidemics  of  typhoid  fever.  In  a 
few  instances  they  have  been  obtained  from  the  blood  during  life  and 
the  spleen  after  death  in  cases  which  clinically  could  not  be  distin- 
guished from  typhoid  fever.  Some  of  them  agglutinate  more  or  less 
markedly  in  blood  serum  obtained  from  individuals  suffering  from 
typhoid  fever.  Many  additional  observations  must  be  made  before 
we  can  determine  with  certaintj^  the  proper  classification  of  these 
organisms.  In  this  connection  we  may  state  that  in  our  investigation 
of  typhoid  fever  in  the  national  encampments  of  1898  we  found  no 
reason  for  supposing  that  the  colon  bacillus  is  ever  transformed  into 
the  typhoid  bacillus.  This  subject  will  receive  additional  attention 
later. 

The  natural  distribution  of  the  typhoid  bacillus  is  another  subject 
needing  careful  investigation.  Apparently  trustworthy  bacteriolo- 
gists have  reported  the  finding  of  this  micro-organism  in  the  most 
unexpected  places.  It  has  been  detected  in  the  soil  of  localities  far 
removed  from  the  habitations  of  man  and  has  been  isolated  from 
drinking  water  supposed  to  be  free  from  contamination.  Further- 
more, its  presence  has  been  reported  in  the  stools  of  healthy  persons 
as  well  as  in  those  suffering  from  dysentery  and  simple  diarrhea.  It 
must  remain  for  future  studies  to  decide  upon  the  reliability  of  tliese 
reported  findings  and  to  attach  to  them  their  proper  significance 
should  they  be  found  to  be  true. 

THE    ELIMINATION    OF    THE    BACILLUS   FROM    THE    BODY. 

It  is  important  in  a  study  of  the  etiolog}'  of  typhoid  fever  to  ascer- 
tain by  what  avenues  the  specific  micro-organism  leaves  the  body  of 
the  infected  individual.  The  exhaled  air  from  the  lungs  of  the 
typhoid-fever  subject  is  germ  free,  as  it  probably  is  in  all  infectious 
diseases.  There  is  therefore  no  possibility  of  this  disease  being 
spread  by  means  of  the  air  exhaled  from  the  lungs.     This  statement 


201 

is  true  only  when  tlie  exhaled  air  is  free  from  sputum.  In  the  pneu- 
monias that  complicate  typhoid  fever  the  Eberth  bacillus  is  found  in 
the  diseased  lungs  and  may  be  eliminated  in  the  matter  coughed  up 
and  disseminated  through  the  air  in  the  fine  spray  that  accompanies 
severe  fits  of  coughing.  However,  the  spread  of  typhoid  fever  in  this 
manner  must  be  regarded  as  a  bare  possibility. 

There  is  no  positive  evidence  that  the  perspiration  from  one  sick 
with  typhoid  fever  contains  the  specific  bacillus  of  this  disease.  It  is 
true  that  this  bacterium  may  be  found  on  the  surface  of  individuals 
sick  with  this  disease,  but  in  such  cases  the  germ  owes  its  presence  in 
this  locality  to  qontamination  of  the  skin  with  the  stools  or  with  the 
urine.  It  is  possible  that  under  exceptional  circumstances  this  bacillus 
may  find  its  way  to  the  surface  from  the  blood,  as  it  occurs  in  the 
eruptive  spots  of  typhoid  fever. 

The  urine  of  one  sick  with  typhoid  fever  may  or  may  not  contain 
the  Eberth  bacillus.  Several  observers  have  found  the  living  virulent 
bacterium  in  the  urine,  especially  when  this  secretion  contains  albumin. 
In  some  of  these  cases  it  is  more  than  probable  that  the  germ  has 
found  lodgment  in  the  kidney  and  has  produced  more  or  less  exten- 
sive structural  changes  in  that  organ.  However,  the  bacillus  may  be 
abundant  in  the  urine  when  this  secretion  contains  no  albumin  and 
when  there  is  no  other  evidence  of  structural  disease  of  the  kidney. 
Persons  recovering  from  typhoid  fever  may  continue  for  weeks  to 
eliminate  in  the  urine  millions  of  the  Eberth  bacillus.  It  sometimes 
happens  that  a  cystitis  occurs  as  a  sequel  to  typhoid  fever.  In  at 
least  some  of  these  cases  the  infiammation  of  the  bladder  is  due  to 
infection  with  the  typhoid  bacillus,  and  this  germ  in  a  virulent  form 
may  after  a  long  time  remain  in  the  bladder  and  render  the  urine  a 
possible  source  of  the  spread  of  typhoid  fever.  Houston  ^  has  reported 
a  case  of  cystitis  of  three  years'  standing  due  to  the  infection  of  the 
bladder  with  the  bacillus  of  Eberth.  An  interesting  point  in  connec- 
tion with  the  report  of  this  case  is  that  the  patient  never  had  typhoid 
fever,  but  had  nursed  cases  of  this  disease.  Further  evidence  will  be 
needed  before  we  can  accept  the  possibility  of  an  infection  of  this 
kind.  However  this  may  be,  the  occurrence  of  the  specific  micro- 
organism in  the  urine  in  cases  of  typhoid  fever  is  of  sufficient  fre- 
quenc}^  to  demand  that  this  secretion  be  disinfected  in  every  case  of 
this  disease.  Post-typhoidal  abscesses  may  form  in  various  parts  of 
the  body  and  may  discharge  the  Eberth  bacillus  in  virulent  form  for 
months  and  even  years.  It  is  unnecessary  to  add  that  infected  mate- 
rial of  this  kind  should  be  burned  or  otherwise  disinfected.  The 
necessitj^  for  this  is  evident  whether  the  abscesses  be  due  to  the 
typhoid  bacillus  or  to  other  bacteria. 

The  most  important  avenue  for  the  elimination  of  the  tj^phoid 
bacillus  from  the  body  is  through  the  bowel.     Long  before  the  dis- 

'  Houston,  British  Medical  Journal,  1899,  vol.  1,  p.  78. 


202 

covery  of  the  specific  micro-organism  of  this  disease  man  had  learned 
that  the  stools  of  tj^hoid  patients  contained  the  infective  agent  of  the 
disease.  It  had  been  frequently  observed  that  epidemics  of  typhoid 
fever  resulted  from  the  drinking  of  water  contaminated  with  the 
stools  of  those  suffering  from  this  disease.  The  more  intelligent 
members  of  the  medical  profession  recommended  thorough  disinfec- 
tion of  the  feces  long  before  the  bacillus  had  been  discovered.  The 
elimination  of  the  typhoid  bacillus  in  the  stools  probably  begins  soon 
after  its  introduction  through  the  mouth.  Indeed,  it  is  quite  certain 
that  an  individual  may  become  the  bearer  and  distributer  of  the 
infecting  agent  of  typhoid  fever  without  developing  the  disease  him- 
self. The  specific  bacterium  finds  its  way  into  the  small  intestines, 
in  the  contents  of  which  it  multiplies  rapidly,  and  this  intestinal  cul- 
ture may  be  wholly  discharged  from  the  bowels  without  inducing  any 
local  lesions.  Furthermore,  as  we  have  already  seen,  typical  typhoid 
fever  may  develop  and  death  result  without  intestinal  ulceration. 

We  desire  to  emphasize  the  fact  that  the  typhoid  bacillus  may  grow 
in  the  intestines  of  an  individual  and  pass  from  the  same  Avithout 
causing  typhoid  fever.  This  is  most  likely  to  occur  when  many  irri- 
tative saprophytic  germs  are  taken  into  the  alimentary  canal  along 
with  a  few  typhoid  bacilli.  A  few  hours  after  infection  ^ith  such  a 
mixed  culture  the  saprophytic  germs  may  cause  a  profuse  dian-hea, 
which  sweeps  from  the  intestines  the  typhoid  bacilli.  This  is  proba- 
bly the  true  explanation  of  the  unquestionable  protective  effect  of 
diarrheas  in  certain  epidemics  of  typhoid  fever.  We  shall  have 
occasion  to  refer  to  this  later.  Moreover,  it  is  probable  that  a  con- 
siderable proportion  of  adult  individuals  are  to  some  extent,  at  least, 
immune  to  typhoid  fever.  The  specific  germ  of  this  disease  may  be 
transported  from  one  place  to  another  in  the  intestines  of  an  immune 
man,  and  when  cast  out  in  the  stools  may  become  a  source  of  danger 
to  others.  It  is  probably  in  some  such  way  as  this  that  epidemics  of 
typhoid  fever  sometimes  aj)pear  to  originate  de  novo. 

The  stools  of  individuals  sick  with  typhoid  fever  constitute  the 
most  important  source  for  the  spread  of  this  disease,  and  it  may  be 
stated  in  a  general  way  that  typhoid  fever  is  due  to  the  transference 
of  some  part  of  the  feces  of  an  infected  individual  to  the  alimentarj^ 
canal  of  one  susceptible  to  this  infection.  This  transference  in 
exceptional  cases  may  be  quite  direct,  as  when  a  careless  nurse  soils 
her  hands  with  the  dejections  from  her  typhoid-fever  patient  and  eats 
her  food  without  disinfecting  her  soiled  fingers.  Generally,  however, 
the  transference  is  more  indirect  and  the  germs  in  the  infected  stools 
may  multiplj"  through  many  generations  and  be  transported  by  water 
or  otherwise  through  considerable  distances.  Moreover,  as  has  been 
indicated  already,  the  bacilli  may  pass  through  an  intermediate  host, 
which  may  be  man  or  one  of  the  lower  animals.  An  immune  indi- 
vidual may  visit  a  distant  city,  the  water  supply  of  which  is  infected 


203 

witli  the  typhoid  bacillus,  and  he  maj^  carry  this  infection  to  his  vil- 
lage home,  where  it  may  be  deposited  in  his  normal  stool,  may  find 
its  way  into  the  local  water  snpplj^,  and  cause  an  epidemic  of  the 
disease. 

Typhoid  bacilli  are  most  abundant  in  the  stools  of  patients  suffer- 
ing from  this  disease  when  there  is  sloughing  of  the  intestinal  ulcera- 
tions. However,  it  should  be  borne  in  mind  that  typhoid  stools  are 
infectious  often  before  the  individual  shows  any  evidence  of  the 
disease.  In  other  words,  the  stool  of  a  man  in  the  incubation  period 
of  typhoid  fever  may  be  laden  with  the  bacilli  of  this  disease.  In 
this  way  every  latrine  in  an  encampment  may  be  infected  with  the 
specific  micro-organism  of  typhoid  fever  before  the  disease  has  devel- 
oped sufficientl}^  in  the  individual  to  be  recognized  clinically.  On  the 
other  hand,  the  stools  may  continue  to  be  infectious  long  after  con- 
valescence has  set  in.  So  great  is  the  danger  of  the  spread  of  this 
disease  from  infected  stools  that  in  all  cases  where  fecal  matter  can 
not  be  removed  by  water  carriage,  or  otherwise,  from  immediate  prox- 
imity^ with  human  habitation,  all  stools,  those  of  both  sick  and  well, 
should  be  thoroughly  disinfected. 

IsTotwithstanding  the  fact  that  the  typhoid  bacillus  is  abundant  in 
the  stools  of  individuals  suffering  from  this  disease,  its  isolation 
and  identification  in  the  feces  is  one  of  the  most  difficult  tasks  under- 
taken by  the  bacteriologist.  This  difficulty  lies  in  the  separation  of 
the  typhoid  bacillus  from  other  bacilli,  which  it  resembles  in  some 
respects  and  Avhieh  are  present  in  the  stools  in  much  larger  numbers. 
The  colon  bacillus,  always  x)resent  both  in  normal  and  tj^phoid  stools, 
grows  so  abundantlj^  and  may  resemble  the  tj'phoid  bacillus  so  closely 
that  the  separation  of  the  two  is  difficult  and  often  impracticable.  It 
is  unfortunate  that  we  have  no  reliable  method  of  detecting  the 
typhoid  bacillus  in  mixed  cultures  of  this  germ  and  the  bacterium 
coli.  Such  a  method  would  supply  us  with  a  more  ready  and  sure 
means  for  the  early  recognition  of  typhoid  fever  than  we  now  possess, 
and  it  is  to  be  hoped  that  future  investigations  will  furnish  a  practi- 
cal solution  of  this  question.  Many  devices  dependent  upon  supposed 
cultural  peculiarities  have  been  j^roposed  and  success  has  been  prom- 
ised many  times,  but  up  to  the  present  no  reliable,  easily  applicable 
method  for  the  detection  of  the  typhoid  bacillus  in  stools  has  been 
discovered. 

LONGEVITY    OF   THE    TYPHOID    BACILLUS. 

It  must  be  evident  that  in  studying  the  i^roblem  of  the  spread  of 
typhoid  fever  it  is  of  the  greatest  importance  that  we  should  know  how 
long  the  specific  bacillus  of  this  disease  will  continue  to  live  and  be 
possessed  of  its  specific  properties.  It  is  equally  evident  that  when 
seeking  for  an  answer  to  this  question  we  must  know  something  of 
the  conditions  under  which  the  life  of  the  organism  is  to  be  perpet- 


204 

uated.  We  have  alreadj"  seen  that  in  the  human  body  the  Eberth 
bacillus  may  continue  to  grow  and  reproduce  its  kind  quite  indefi- 
nitely. This  is  shown  to  be  the  case  in  instances  of  post-typhoidal 
cystitis  and  abscess.  We  would  not  have  it  understood  that  we  sup- 
pose cases  of  tj^phoid  fever  to  be  frequently  due  to  infection  from  these 
sources,  and  we  have  mentioned  these  facts  simply  for  the  purpose  of 
showing  how  long  an  individual  may  retain  the  Eberth  TDacillus  in 
some  part  of  his  body  Certainly  there  is  a  possibility  of  infection 
spreading  to  others  from  the  germ  found  in  these  post-typhoidal  con- 
ditions, but  such  cases  must  be  rare,  except  when  the  urine  is  infected. 
Probably  the  greatest  source  of  danger  in  these  conditions  is  to  be 
found  in  the  fact  that  the  urine  and  the  stools  of  individuals  who  have 
recovered  from  typhoid  fever  may  continue  to  furnish  the  infective 
agent  for  a  long  time. 

The  living  germ  has  been  found  in  the  bodies  of  men  dead  from 
typhoid  fever  after  three  months.  However,  the  longevity  of  this 
bacillus  in  the  dead  body  must  be  very  variable  and  dependent  upon 
a  number  of  conditions  which  are  not  likely  to  be  exactly  the  same  in 
any  two  cases. 

So  far  as  the  spread  of  typhoid  fever  is  concerned,  the  longevity  of 
its  bacillus  after  it  leaves  the  body  of  the  infected  man  is  of  greater 
importance  than  its  possible  longevity  in  the  body.  When  material 
containing  this  germ  is  spread  out  in  a  thin  layer  and  exposed  to  the 
direct  action  of  the  sunlight,  the  bacilli  are  soon  destroyed.  A  cloth 
moistened  with  a  culture  of  the  Eberth  bacillus  and  exposed  to  the 
direct  sunlight  soon  fails  to  yield  a  growth  when  a  bit  of  it  is  placed 
in  a  suitable  culture  medium.  However,  we  must  not  get  too  much 
comfort  out  of  the  fact  that  the  typhoid  bacillus  is  killed  by  an  expos- 
ure of  a  few  hours  to  the  light  of  the  sun.  Practically  typhoid  stools 
are  not  spread  out  in  thin  layers  or  otherwise  placed  in  a  condition 
necessary  for  the  light  to  have  a  markedly  germicidal  action.  In  the 
interior  of  a  mass  of  fecal  matter  the  germ  may  retain  its  vitality  for 
a  long  time.  It  is  true  that  the  bacilli,  when  a  small  quantity  of 
tj^phoid  stool  is  smeared  on  a  sheet,  may  be  destroyed  by  a  few  hours' 
exposure  to  direct  light,  but  the  same  material  rolled  in  heavy  blankets 
may  retain  its  virulence  for  many  weeks.  Complete  desiccation  soon 
destroys  the  Eberth  bacillus,  but  it  may  retain  its  vitality  in  relatively 
dry  material  for  a  long  period.  Bits  of  agar  or  gelatine  cultures  placed 
upon  cloth,  leather,  wood,  or  metal  retain  the  living  bacillus  for  many 
months,  and  clothing  and  bedding  soiled  with  typhoid  stools  may  be 
the  means  of  spreading  this  disease.  The  experiments  of  Uffelmann^ 
show  that  the  bacillus  may  retain  its  vitality  in  layers  4  mm.  thick  on 
wood  for  thirty-two  days,  on  linen  for  sixty  days,  and  on  woolen  cloth 
for  eighty  days. 

The  experiments  that  have  been  made  in  order  to  determine  the 


'Uffelmann,  Centralblatt  fiir  Bakteriologie  und  Parasetenkunde,  1894. 


205 

longevity  of  this  bacillus  in  the  soil  have  yielded  mdely  different 
results.  This  is  explained  by  the  fact  that  no  two  investigators  have 
experimented  under  exactly  the  same  conditions.  When  cultures  of 
the  Eberth  bacillus  are  mixed  with  dust  or  pulverized  earth  of  any 
kind  and  completely  desiccated  the  germs  speedily  die,  but  when  the 
desiccation  is  not  complete  the  bacilli  may  retain  their  vitality  for 
weeks  and  months.  Because  desiccation  soon  destroys  the  germ  of 
typhoid  fever,  it  has  been  inferred  that  this  disease  can  not  be  spread 
by  means  of  particles  of  dust  carried  through  the  air.  We  will  return 
later  to  a  discussion  of  this  point,  but  it  may  be  stated  here  that 
particles  of  dust  carried  through  the  air  are  by  no  means  always  com- 
pletely desiccated.  Currents  of  air  may  and  do  carry  through  great 
distances  considerable  particles  of  moist  dust.  Considerable  interest 
is  attached  to  the  question  of  the  vitality  of  this  organism  in  the  soil 
about  sinks  and  privies  containing  typhoid  stools.  After  the  Franco- 
German  war  it  was  found  that  typhoid  fever  continued  to  prevail  for 
some  years  in  German  garrisons  in  which  German  soldiers  or  French 
prisoners  sick  with  typhoid  fever  had  lived.  One  interesting  case  of 
this  kind  may  be  referred  to.  In  this  instance  an  epidemic  of  typhoid 
fever  began  among  German  soldiers  located  in  a  certain  garrison  on 
April  4,  1872.  During  the  war  these  barracks  had  been  occupied  by 
French  prisoners  among  whom  typhoid  fever  had  prevailed.  Large 
sinks  had  been  filled  with  the  undisinfected  stools  of  the  prisoners, 
and  when  full  these  pits,  which  were  located  just  outside  the  bar- 
racks, were  covered  in  with  thin  layers  of  earth.  The  water  of  a  well 
near  by  had  probably  become  infected  from  these  sinks  and  caused 
the  epidemic  in  the  garrison  in  1872.  These  old  sinks  were  cleaned 
out  and  the  well  closed.  Four  days  later  the  last  case  of  typhoid 
fever  occurred  in  this  garrison. 

Recently  interesting  experiments  have  been  made  in  England  for 
the  purpose  of  determining  the  longevity  of  the  typhoid  bacillus  in 
soil.  Martin  took  specimens  of  dirt  from  various  sources.  Some  of 
these  samples  were  obtained  from  localities  where  it  was  known  that 
•the  soil  was  largely  contaminated  with  organic  matter  and  where 
typhoid  fever  had  been  endemic;  others  were  obtained  from  places 
which  had  not  been  contaminated  by  sewage  or  in  any  other  way. 
These  samples  of  soil  were  pulverized,  placed  in  Erlenmeyer  flasks 
and  sterilized,  after  which  they  were  inoculated  with  cultures  of  the 
typhoid  bacillus.  It  was  found  that  the  Eberth  bacillus  grew  luxuri- 
antly in  the  polluted  earth,  and  that  flasks  containing  this  soil  showed 
active  growths  of  this  microorganism  after  the  lapse  of  105  daj^s. 
The  results  obtained  with  the  unpolluted  earth  were  quite  different. 
In  these  soils  the  germ  not  only  failed  to  multiply,  but  after  a  short 
time  it  died  out. 

Investigations  by  Klein  indicate  that  the  process  of  nitrification  as 
it  goes  on  in  soil,  favors  the  growth  and  development  of  the  typhoid 


206 

bacillus.  Klein  had  ascertained,  as  others  before  him  had  done,  that 
sewage  is  not  a  suitable  medium  for  the  growth  of  this  bacillus,  but 
subsequently  he  found  that  by  the  addition  of  nitrates  to  crude  sew- 
age the  latter  is  converted  into  a  more  suitable  medium  for  the  growth 
of  this  organism.  In  fact,  in  this  modified  sewage  the  typhoid  bacillus 
grows  abundantly. 

Robertson  selected  a  grass-covered  field  for  his  investigations. 
Patches  of  turf  were  cut  and  removed  from  the  subjacent  soil.  At  one 
place  the  ground  immediately  below  the  turf  was  watered  with  the 
bacillus,  after  which  the  turf  was  replaced.  In  another  locality  9 
inches  of  the  earth  beneath  the  turf  was  removed  and  the  Eberth 
bacillus  sown  at  this  depth;  while  in  a  third  experiment  the  germ 
was  placed  at  a  depth  of  18  inches,  the  soil,  which  had  been  removed, 
being  carefully  replaced  after  depositing  the  germ.  One  hundred 
and  thirty  days  after  this  had  been  done  the  soil  under  the  turf  of  the 
infected  localities  was  removed  and  examined.  Robertson  found 
that  in  all  cases  the  bacilli  had  not  only  retained  their  vitality,  but 
had  multiplied.  In  the  locality  where  the  germ  had  been  placed  18 
inches  beneath  the  surface  it  had  grown  through  the  earth  above  it, 
where  it  was  found  widely  and  abundantly  distributed.  Some  of 
these  plantings  were  made  in  July,  1895.  During  the  cold  months  of 
the  following  winter  no  tj^hoid  bacilli  could  be  obtained  from  the 
soil  in  which  they  had  been  deposited.  During  the  following  spring 
these  spots  were  treated  with  dilute  sterile  broth  in  order  to  furnish 
material  for  the  growth  of  the  germ  and,  furthermore,  for  the  purpose 
of  rendering  the  conditions  similar  to  those  existing  in  cases  of  pollu- 
tion with  sewage.  It  was  found  in  the  following  June,  nearly  a  year 
from  the  time  of  the  j)lanting  of  the  germ,  that  those  localities  which 
had  been  properlj^  fertilized  with  the  beef  broth  furnished  an  abun- 
dant crop  of  the  germ,  while  areas  which  had  not  been  so  fertilized 
failed  to  show  any  growth. 

These  experiments  indicate  that  a  polluted  soil  when  once  infected 
with  the  typhoid  bacillus  may  retain  the  infection  for  a  long  time, 
and  they  are  quite  in  accord  with  military  experience,  inasmuch  as 
it  has  frequently  been  found  that  a  healthy  regiment  may  speedily 
develop  this  disease  after  occupying  a  site  vacated  by  an  infected 
command.  The  historj^  of  typhoid  fever  among  the  troops  during 
the  war  of  the  rebellion  furnishes  instances  of  this  kind,  one  or  two 
of  which  may  be  mentioned. 

The  Twentj^-third  Massachusetts,  numbering  900  men,  left  Massa- 
chusetts in  November,  1861,  and  were  encamped  at  Annapolis,  Md., 
until  January  8,  1862,  the  record  of  health  being  good  during  this 
time.  The  regiment  arrived  at  Roanoke  Island  February  7,  1862, 
from  whence  it  embarked  to  Newbern,  N.  C,  arriving  at  this  place 
March  14,  1862.  According  to  the  report  of  the  regimental  surgeon, 
Oeorge  Derby,  the  health  of  the  regiment,  in  spite  of  exposure  to  many 


207 

hardships,  had  been.  good.  Arriving  at  ISTewberne  the  regiment 
occupied  an  encampment,  including  tents,  abandoned  by  a  Confederate 
regiment  that  had  suffered  severely  from  typhoid  fever.  The  disease 
soon  appeared  among  the  men  of  the  Massachusetts  regiment  (the 
number  of  days  before  the  appearance  of  the  first  case  is  not  stated), 
and  during  the  month  of  April,  1862,  300  cases  developed  and  22 
deaths  occurred. 

On  March  7, 1862,  the  Tenth  New  York  Cavalry  moved  into  barracks 
at  Perrj'ville,  Md.,  which  had  recently  been  vacated  by  the  Fourteenth 
U.  S.  Inf antr3\  The  latter  regiment  had  suffered  largely  from  typhoid 
fever  during  the  month  of  February,  1862.  The  barracks  were  thor- 
oughly cleaned,  drains  opened  and  improved,  and  an  excellent  spring, 
which  was  exempt  from  any  source  of  pollution,  was  found.  The 
Fourteenth  Infantry  had  used  water  from  a  well  only  6  feet  deep  and 
this  had  been  supposed  to  be  the  source  of  the  typhoid  fever.  Notwith- 
standing the  precautions  taken  by  the  New  York  regiment,  diarrhea 
and  so-called  malarial  fever  soon  appeared.  On  March  26,  1862,  the 
New  York  regiment  was  moved  across  the  bay  to  Havre  de  Grace,  and 
the  following  morning  numerous  cases  of  so-called  remittent  fever 
reported  at  sick  call  and  soon  diarrhea  became  epidemic  in  the  com- 
mand. The  monthly  report  of  sick  and  wounded  for  April  shows  28 
cases  of  remittent  fever  and  2  cases  of  typhoid  fever.  It  can  hardly 
be  doubted  that  all  these  cases  of  fever  were  in  reality  typhoid,  and 
that  they  were  contracted  through  the  occupancy  of  an  already  infected 
locality. 

The  following  illustrates  British  experience  in  India  bearing  on  this 
point:  In  January,  1890,  a  battalion  of  a  South  Wales  regiment  occu- 
pied a  certain  site  at  Bareilly,  and  while  there  suffered  severely  with 
typhoid  fever.  On  account  of  this  outbreak  this  battalion  was  moved 
to  another  location.  In  the  following  November  a  battalion  of  the 
Royal  Munster  Fusiliers  came  to  Bareilly  and  was  located  on  the  spot 
occupied  by  the  South  Wales  regiment  nine  months  before.  Within 
three  weeks  after  occupation  of  this  locality  by  the  Fusiliers  cases  of 
typhoid  fever  began  to  develop.  After  consultation  it  was  decided  to 
move  the  camp  1:^  miles  farther  west ;  when  this  was  done  the  epidemic 
abated. 

That  the  floors,  furniture,  and  bedding  of  barracks  may  become 
infected  with  typhoid  fever  and  may  continue  to  endanger  the  life  and 
health  of  its  occupants  for  a  long  time  is  abundanth*  shown  in  the 
records  of  militarA'  surgeons.  The  following  report  by  Chour,  a  Rus- 
sian medical  officer,  is  an  instance:  A  typhoid  epidemic  appeared 
in  two  infantry  regiments  garrisoned  at  Jitomir.  All  the  soldiers  of 
these  two  regiments  obtained  their  drinking  water  from  the  same 
source.  One  regiment  had  in  1885,  9.6,  and  in  1886,  3.2  per  mille  cases 
of  typhoid  fever.  The  second  regiment  had  during  the  same  time  a 
similar  proj^ortion  of  eases,  but  in  one  company  of  the  second  regiment 


208 

14  out  of  90  men  were  stricken  with  tj^phoid  fever.  The  extraor- 
dinarj^  number  of  cases  of  this  disease  in  this  company  led  to  the 
supposition  that  the  part  of  the  garrison  occupied  by  these  men  was 
specificallj''  infected.  In  December,  1886,  the  room  occupied  by  this 
company  was  vacated  and  subjected  to  thorough  disinfection.  The 
walls,  the  floor,  and  the  furniture  of  the  room,  also  the  clothing  of  the 
soldiers,  were  disinfected.  After  this  had  been  done  this  company 
was  allowed  to  return  to  its  own  quarters.  In  1887  the  number  of 
cases  of  typhoid  fever  in  this  company  was  reduced  to  1.7  per  mille, 
and  in  1886  there  was  not  a  case.  However,  during  the  same  time, 
typhoid  fever  increased  among  the  soldiers  occupying  parts  of  the  gar- 
rison which  had  not  been  disinfected.  The  disappearance  of  the  dis- 
ease among  the  soldiers  that  occupied  the  disinfected  quarters  and  its 
persistence  and  increase  among  the  soldiers  in  the  undisinfected  quar- 
ters led  Chour  to  conclude  that  the  typhoid  bacillus  was  disseminated 
through  the  dust  in  the  rooms.  It  maybe  that  the  bedding  and  cloth- 
ing of  the  soldiers  were  soiled  mth  typhoid  stools,  and  the  bacilli  may 
have  been  transferred  from  these  soiled  articles  to  the  alimentarj^ 
canal  by  means  of  the  fingers,  or  it  is  possible  that  the  dust  from  the 
infected  clothing  carried  the  specific  bacillus  through  the  air  which 
was  inhaled  by  the  occupants  of  the  room.  This  and  other  equally 
striking  instances  of  garrison  infection  show  the  necessity  of  thorough 
disinfection  of  quarters  infected  "\vith  typhoid  fever. 

It  will  be  seen  from  the  above  that  both  experimental  evidence 
obtained  with  pure  cultures  of  the  bacillus  and  epidemiological  observa- 
tion in  the  study  of  typhoid  fever  show  that  Infected  things  and  places 
may  remain  sources  of  danger  for  weeks  and  months.  These  facts 
have  not  been  sufficiently  impressed  upon  the  medical  profession,  and 
the  necessity  of  thorough  disinfection  of  soiled  clothing  and  bedding, 
etc.,  has  not  been  appreciated.  The  history  of  outbreaks  of  typhoid 
fever  among  our  soldiers,  as  detailed  in  this  report,  will  emphasize 
the  necessity  of  giving  more  attention  to  disinfection  after  typhoid 
fever. 

Since  epidemics  of  typhoid  fever  are  f requentl}^  spread  by  means  of 
drinking  water,  the  longevity  of  the  bacillus  in  this  medium  is  of  con- 
siderable importance.  Many  experiments  have  been  made  for  the 
purpose  of  obtaining  information  on  this  subject.  Evidentlj^  the  con- 
ditions influencing  the  life  of  the  bacillus  are  not  likeh^  to  be  identical 
in  any  two  sources  of  water  supply.  In  distilled  water  and  sterilized 
drinking  water  obtained  from  springs,  wells,  rivers,  and  lakes,  and 
kept  at  ordinary  room  temperature  without  exposure  to  direct  sun- 
light, the  typhoid  bacillus  may  rapidly  multiply  and  may  retain  its 
vitality  for  three  or  four  months.  Exposure  of  infected  water  in 
shallow  vessels  to  direct  sunlight  hastens  the  destruction  of  the  bacilli. 
A  like  effect  is  produced  when  the  water  is  frequently  and  violently 
agitated.     In  ordinary  unsterilized  water  the  conditions  that  influence 


209 

the  life  of  the  t^^phoicl  bacillus  are  many  and  varied.  In  the  first 
place,  the  chemical  composition  of  the  water  is  not  without  effect 
upon  the  longevity  of  the  tj^phoid  bacillus.  As  has  already  been 
stated,  sewage  ordinarily  does  not  form  a  good  medium  for  the  growth 
of  this  germ,  but,  as  Klein  has  shown,  the  addition  of  nitrates  renders 
the  growth  abundant,  and  that  processes  of  nitrification  are  constantly 
going  on  in  polluted  water  is  shown  by  the  presence  of  nitrites  and 
nitrates.  Evidently  the  kind  and  number  of  other  geimis  present  in 
a  foul  water  have  much  to  do  in  determining  the  longevity  of  the 
typhoid  bacillus  in  such  mixed  cultures.  Some  of  the  ordinary  water 
bacteria  undoubtedlj^  hasten  the  death  of  the  bacillus,  owing  to  the 
fact  that  the  conditions  of  growth  are  more  favorable  to  the  former 
than  to  the  latter.  However,  experimental  evidence  on  this  point  is 
not  always  conclusive,  because  the  water  bacteria  are  present  in  rela- 
tively much  greater  numbei*s  than  the  tj'phoid  bacillus,  and  failure  to 
detect  and  isolate  the  latter  is  not  always  convincing  proof  of  its 
absence.  In  fact,  the  detection  of  the  typhoid  bacillus  when  added 
in  small  amount  to  a  large  volume  of  water  containing  numerous 
germs  of  different  species  is  by  no  means  an  easy  task,  and  so  far  as 
the  detection  of  this  organism  in  natural  waters  suspected  of  having 
caused  typhoid  fever  is  concerned,  it  is  doubtful  whether  anyone  up 
to  the  present  time  has  succeeded  in  isolating  from  such  water  a  typ- 
ical Eberth  bacillus.  It  is  not  to  be  inferred  from  this  that  the  typhoid 
organism  is  not  present  in  such  waters,  but  the  difficulty  lies  in  its 
separation  and  specific  identification.  Moreover,  it  is  altogether 
probable,  indeed  we  may  say  quite  certain,  that  after  the  Eberth  bacil- 
lus has  grown  for  several  generations  in  water  it  shows  cultural  varia- 
tions from  the  tj-pical  bacillus  obtained  from  the  spleens  of  persons 
dead  from  tyi)hoid  fever. 

Westcott  ^  reports  a  case  of  apparently  great  longevity  of  the  typhoid 
bacillus  in  water.  He  states  that  he  was  able  to  trace  19  cases  of 
typhoid  fever  to  a  well  draT\^ng  its  supply  from  a  sewage-contaminated 
area.  On  closing  the  well  the  epidemic  ceased,  but  on  reopening  it 
for  the  purpose  of  obtaining  water  for  laundry  purposes  another  case 
occurred.  The  well  had  been  closed  twenty  months,  and  during  this 
time  the  conditions  were  such  that  the  introduction  of  further  con- 
tamination was  improbable. 

The  belief  that  commercial  table  waters  are  always  safe  is  by  no 
means  justified.  Many  of  these  are  ordinary  waters  taken  from 
diverse  sources  and  charged  with  carbonic-acid  gas.  In  such  a  water 
the  typhoid  bacillus  may  retain  its  vitality  for  a  long  time.  It  must 
be  evident  that  the  purity  of  a  commercial  table  water  depends  upon 
its  source  and  the  care  and  skill  exercised  in  handling  it.  It  may  be 
remarked  here,  parenthetically,  that  some  of  the  commercial  waters 


Westcott,  Joui-nal  of  State  Medicine,  vol.  7,  p.  104. 


210 

sent  to  Sternberg  Hospital,  at  Chickamanga,  in  1898,  contained  a  suf- 
ficiently large  number  of  germs  to  condemn  their  use.  In  fact,  they 
contained  more  germs  per  cubic  centimeter  than  the  waters  obtained 
from  springs  and  wells  in  and  about  the  park.  We  do  not  mean  to 
say  that  the  typhoid  bacillus  was  found  in  any  of  these  commercial 
waters,  but  we  do  mean  to  say  that  they  were  too  filthy  to  be  used  as 
drinking  water. 

In  certain  liquid  foods,  such  as  milk,  bouillon,  and  broth,  the 
typhoid  bacillus  may  retain  its  natality  for  months.  This  is  true 
whether  the  food  be  sterilized  or  unsterilized  at  the  time  of  the  intro- 
duction of  this  organism.  When  deposited  on  solid  food,  such  as 
potatoes,  bread,  and  meat,  the  typhoid  bacillus  may  retain  its  vitality 
as  long  as  such  foods  are  likely  to  remain  j)alatable.  In  other  words, 
this  bacterium,  when  deposited  on  such  foods,  may  retain  its  virulence 
until  putrefactive  changes  become  markedly  advanced.  We  will 
return  later  to  a  discussion  of  the  spread  of  typhoid  fever  through 
infected  articles  of  food. 

Since  the  Eberth  bacillus  forms  no  spores,  it  is  easily  destroyed  by 
a  sufficiently  high  temperature.  In  boiling  water  it  is  instantly 
killed,  and  a  like  result  is  obtained  by  a  ten  minutes'  exposure  to  a 
temperature  of  60°  C.  Low  temperatures  prevent  multiplication,  but 
do  not  destroy  the  bacilli.  They  may  remain  frozen  in  ice  for  months 
without  appreciable  loss  in  vitality  or  virulence.  Furthermore,  alter- 
nately freezing  and  thawing  of  cultures  of  this  bacillus  repeated  indefi- 
nitely are  apparently  without  effect.  The  evidence  that  certain  small 
epidemics  of  typhoid  fever  have  been  due  to  infected  ice  is  quite 
j)0sitive. 

From  the  preceding  statements  it  must  be  evident  that  the  typhoid 
bacillus  is  capable  of  retaining  both  vitality  and  virulence  for  months 
after  it  has  been  discharged  from  the  body.  Not  only  is  this  true,  but 
it  may  multiply  both  in  the  soil  and  in  water. 

THE    DISSEMINATION    OF   TYPHOID. 

{a)  Transported  by  man. 

Man  himself  is  the  most  active  agent  in  the  dissemination  of  this 
disease.  He  may  carry  the  specific  virus  in  his  alimentary  canal,  on 
his  person,  or  in  his  clothing.  In  this  way  the  germs  of  the  disease 
may  be  carried  hundreds  and  thousands  of  miles  and  may  be  widely 
distributed.  An  infected  recruit  may  plant  the  specific  bacillus  of 
this  disease  in  every  latrine  in  his  regiment  before  he  is  suspected  of 
having  the  disease  himself.  So  widespread  is  typhoid  fever  that  in 
assembling  a  regiment  of  volunteers  it  may  be  assumed  that  among 
these  men  thei'e  are  one  or  more  infected  with  this  disease.  Practically, 
typhoid  fever  is  always  imported  into  military  camps,  and  having  been 
thus  introduced  it  too  frequently  finds  conditions  favorable  for  its 
spread. 


211 

In  the  history  of  the  war  of  the  rebellion  there  is  but  little  informa- 
tion concerning  the  importation  of  typhoid  fever,  more  attention  being 
given  to  general  reports  concerning  hard  service,  inclemency  of  the 
weather,  and  insanitary  conditions  in  camp  as  connected  with  the 
prevalence  of  this  disease.  More  importance  is  attached  to  exposures, 
hardships,  the  unaccustomed  mode  of  life  of  the  young  soldiers,  over- 
crowding and  bad  ventilation,  than  to  imiDortation  of  the  disease  from 
the  localities  where  the  men  were  recruited,  although  this  is  occa- 
sionall}'  suggested.  The  absence  of  special  reports  on  the  causation 
of  typhoid  fever  in  the  camps  was  attributed  to  the  difficulties  attend- 
ing an  investigation  into  the  origin  and  transmission  of  this  disease, 
owing  to  the  existence  of  unknown  and  unsuspected  factors. 

When  the  Franco-German  war  began  every  corps  of  the  German 
army  was  infected  with  typhoid  fever,  and  the  second  division  of  the 
Eleventh  Corps  was  having  at  that  time  a  marked  e]3idemic  of  this 
disease.  The  following  figures  show  the  number  of  cases  of  typhoid 
fever  in  each  corps  of  the  Prussian  army  on  June  15,  1870: 


General  Corps 
First  Corps  . . . 
Second  Corps . 
Third  Corps.. 
rourthCorps- 
Pifth  Corps... 


Num- 

Rate per 

ber  of 

thou- 

cases. 

sand. 

33 

1.3 

18 

1.3 

r 

.51 

10 

.68 

6 

.43 

9 

.68 

Sixth  Corps  

Seventh  Corps . 
Eighth  Corps  . . 
Ninth  Corps  .-. 
Tenth  Corps  _ . . 
Eleventh  Corps 


Num- 
ber of 
cases. 


Rate  per 
thou- 
sand. 


3.1 
1.3 
.93 

.67 
1.6 
3.0 


The  infection  was  not  confined  to  the  Prussians,  but  extended  to 
every  contingent  of  the  German  army.  The  seeds  of  the  disease  car- 
ried with  them  rapidly  bore  fruit,  especially  among  the  troops  besieg- 
ing Metz  and  later  among  those  besieging  Paris.  Within  less  than 
two  months  after  war  was  proclaimed,  typhoid  fever  had  extended  so 
widely  among  certain  divisions  of  the  German  troops,  notably  in  the 
Eleventh  Corps  of  the  Prussian  army  and  in  the  Wurtemburg  division, 
that  more  than  15  per  cent  of  the  men  of  these  commands  were  sick 
with  this  disease.  The  total  number  of  cases  among  the  under  officers 
and  men  in  the  German  army  during  the  Franco-German- war  amounted 
to  73,396,  which  is  equivalent  to  9.31  per  cent  of  the  average  strength 
of  the  army.  It  will  be  remembered  that  the  invasion  of  France  began 
about  the  middle  of  July,  1870.  During  the  second  half  of  this  month 
the  total  number  of  cases  in  the  German  army  was  345,  less  than  the 
average  for  preceding  years  of  peace.  In  August  the  number  percep- 
tibly increased,  amounting  to  2.6  per  thousand,  but  this  was  not  suffi- 
cient to  cause  any  alarm,  and  up  to  the  beginning  of  September  it 
could  not  be  said  that  there  was  an  unusual  prevalence  of  this  disease. 
However,  early  in  this  month  there  was  an  explosive  outbreak  and  the 
cases  ran  uj)  to  12,463,  which  was  equivalent  to  15.3  per  thousand. 
October  showed  17,253  new  cases.     In  this  month  the  epidemic  reached 


212 

its  climax,  fell  slowh^  until  January,  1871,  and  more  rapidly  to  June, 
but  at  the  last-mentioned  date  it  had  not  reached  the  peace  level. 
During  the  fall  of  1870  there  was  not  a  regiment  in  the  German  army- 
free  from  typhoid  fever.  In  addition  to  the  importation  of  typhoid 
fever,  the  Germans  invaded  a  country  in  which  this  disease  was  then 
and  is  at  all  times  practically  endemic.  However,  the  point  which  we 
wish  to  emphasize  here  is  that  the  invading  army  transported  typhoid 
fever  with  it,  and  that  from  seeds  thus  carried  the  disease  spread  until 
no  regiment  remained  free  from  it. 

Typhoid  fever  may  be  transported  along  with  an  army  into  regions 
where  man  has  never  previously  been.  This  was  illustrated  in  the 
Afghan  war,  from  1878  to  1880.  Several  of  the  encampments  of  the 
English  soldiers  during  this  invasion  of  Afghanistan  occupied  posi- 
tions probably  never  before  occupied  by  human  beings.  It  is  not  at 
all  likel}^  that  the  water,  which  was  obtained  from  mountain  streams 
in  the  invaded  region,  was  specifically  contaminated  with  the  virus 
of  typhoid  fever;  nor  was  it  likely  that  the  virgin  soil  covered  by 
these  encampments  was  infected,  except  as  it  became  so  by  occupa- 
tion, and  yet  tj^phoid  fever  occurred  at  nearly  every  station  occupied 
by  the  English  troops.  Only  one  explanation  of  the  prevalence  of  this 
disease  in  these  places  seems  possible.  It  is  known  that  the  English 
troops  which  had  been  encamped  in  various  parts  of  India  were  widely 
infected  with  typhoid  fever  when  the  invasion  of  Afghanistan  was 
begun.  A  similar  experience  is  furnished  by  the  history  of  French 
expeditions  in  northern  Africa.  In  the  Oran  campaign  in  1885  French 
commands  encamped  in  desert  stations  never  before  occupied,  and 
in  these  typhoid  fever  not  only  appeared,  but  acquired  epidemic 
proportions. 

In  the  Suakin  exx)edition  of  1885  every  precaution  was  taken  to 
insure  a  pure  water  supply  for  the  troops.  In  fact,  all  the  drinking 
water  was  distilled.  Notwithstanding  this  fact  typhoid  fever  pre- 
vailed quite  extensively.  At  least  one  regiment,  the  East  Surrey, 
joined  the  exiDcdition  already  infected  with  typhoid  fever.  It  is  more 
than  likely  that  these  men  infected  the  latrines  and  that  flies  aided 
in  the  distribution  of  the  disease. 

In  the  expedition  for  the  relief  of  Chitral,  from  March  28  to  August 
24,  1895,  typhoid  fever  was  carried  along  with  the  English  soldiers. 
The  first  recognized  case  of  this  disease  occurred  April  29,  although 
this  had  been  i3receded  by  several  other  cases  the  diagnosis  of  which 
had  been  doubtful  at  the  time  and  which  had  been  transferred  to  base 
hospitals,  proving  later  to  be  ty]3hoid  fever.  The  expedition  con- 
sisted of  two  regiments,  with  a  total  strength  of  1,601  ofiicers  and 
men.  After  battles  at  Malakand  and  Kahr,  April  3  and  4,  these  regi- 
ments were  encamped  at  Kahr,  in  the  Swat  Valley,  2,000  feet  above 
sea  level.  The  health  was  good  at  first,  but  with  the  increasing  heat 
the  men,  who  were  very  much  crowded  together  in  small  single  fly  tents. 


213 

began  to  suffer  from  malarial  fever,  and  typhoid  fever  soon  made  its 
appearance.  From  April  29  to  August  4,  the  time  of  the  arrival  of 
the  expedition  atLaram  Kotal,  172  cases,  with  39  deaths,  were  reported. 
In  regard  to  this  epidemic,  Surgeon  Major-General  Mansell  makes  the 
following  statement : 

The  first  case  *  *  *  on  April  29  was  probably  imported  from  India.  Once 
the  disease  was  introduced  into  such  camps  as  the  troops  occupied  first  at  Kahr, 
and  later  on  at  Laram  Kotal,  and  bearing  in  mind  the  predisposing  influences  of 
climate  and  other  conditions  of  the  former  place  in  Maj%  when  the  men  were 
inactive,  the  hard  work  they  subsequently  underwent  road  making,  the  gradual 
touhng  of  the  soil  through  the  extension  of  latrine  trenches,  the  inadequate  con- 
servancy arrangements  due  to  the  want  of  a  sufficient  establishment,  it  is  not 
difficult  to  account  for  the  rapid  spread  of  the  disease.  The  milk  and  bazaar  sup- 
plies were,  of  course,  liable  to  suspicion,  but  both  were  under  strict  supervision, 
and  the  outbreak  can  not,  in  my  opinion,  be  attributed  to  them.  The  water  sup- 
ply, which  was  bad  at  Kahr,  may  also  be  disregarded  as  the  cause,  as  when  the 
troops  moved  to  Laram,  where  the  supply  was  excellent,  the  epidemic  increased 
in  virulence.  I  attribute  the  disease  to  the  fouling  of  the  ground,  inevitable  in 
camps,  the  lack  of  sufficient  conservancv  establishments,  the  contamination  of 
food,  etc.,  through  the  agency  of  dust  and  flies,  and  the  necessary  crowding,  dirt, 
and  intimate  contact  in  which  the  men  lived,  often  1  think  carrying  the  infective 
germ  from  one  to  another.  The  absence  of  these  last  conditions  goes  far  to 
explain  the  remarkable  immunity  from  the  disease  that  the  officers  enjoyed. 

When  the  English  invaded  Egypt  in  1882,  some  of  the  regiments 
which  had  been  withdrawn  from  Mediterranean  stations,  and  which 
constituted  a  part  of  the  army  of  invasion,  were  infected  with  typhoid 
fever  before  leaving  their  stations.  Soon  after  disembarking  at 
Ismailia  occasional  cases  of  typhoid  fever  began  to  apiDcar.  The  dis- 
ease was  at  first  diagnosed  remittent  fever,  but  as  it  did  not  yield  to 
quinine  in  full  doses,  two  autopsies  were  held,  and  these  showed  the 
lesions  of  typhoid  fever.  From  Ismailia  the  disease  accompanied  the 
troops  until  the  army  took  up  its  permanent  camp  at  Cairo,  at  which 
place  it  culminated  in  a  serious  epidemic.  The  camp  sites  of  the 
several  regiments  were  situated  on  sandy  soil  and  were  some  distance 
apart,  and  the  latrines  were  easily  dug  and  regularly  filled  up;  fre- 
quent inspection  failed  to  show  any  sanitary  defect.  All  excreta 
from  fever  patients,  as  well  as  bedding  and  clothing  used  by  them, 
were  at  once  disinfected.  The  excreta  were  deposited  in  a  si^ecial 
pit ;  all  the  water  was  boiled  and  filtered.  Notwithstanding  this,  many 
of  the  hospital  corps  men  contracted  the  disease  in  removing  the 
excreta  of  imtients.  On  the  march  from  Ismailia  to  Cairo  the  troops 
drank  canal  water;  but  that  this  water  did  not  occasion  the  epidemic 
appears  to  be  borne  out  by  the  immunity  from  tyj^hoid  fever  enjoyed 
by  the  Indian  contingent  and  the  Seaforth  Highlanders,  although 
using  the  same  water.  The  Manchester  regiment  also,  which  garri- 
soned Ismailia — the  termination  of  the  canal — and  used  this  water,  had 
only  one  case.  The  Household  Cavalry  and  the  Fourth  Dragoon 
Guards  which  were  in  the  desert  during  the  whole  of  the  campaign, 


214 

having  hard  work,  suffering  mucli  exposure,  drinking  bad  water,  and 
living  in  insanitary  camps,  sulf  ered  comparatively  little.  The  Seventh 
Dragoons  and  the  Nineteenth  Hussars  remained  long  in  camp  at  Cairo 
and  suffered  greatly,  the  disease  being  most  prevalent  among  them 
during  the  months  of  November  and  December. 

According  to  Surgeon-Major  Tarrant,  the  epidemic  of  typhoid  fever 
which  prevailed  among  the  English  and  native  troops  in  the  Zulu 
war  (1878-79)  was  imported  into  Fort  Pearson  from  Thring's  Post 
and  Saccharine.  In  regard  to  the  same  epidemic,  Major  Hodgson 
states : 

Numbers  of  men  came  from  Fort  Chelmsford  with  remittent  and  simple  con- 
tinued fev^er,  of  which  a  large  portion  proved  to  be  enteric.  In  a  general  way, 
though  a  large  proportion  of  the  fevers  were  returned  as  simple  continued,  my 
impression  is  that  nearly  all  of  the  cases  were  enteric  of  the  milder  or  more  severe 
type.  From  such  inquiries  as  I  was  able  to  institute,  I  concluded  that  enteric 
fever  was  originally  brought  from  Durban  and  was  carried  by  the  troops  to  the 
various  stations  where  it  broke  out,  and  that  in  all  cases  it  was  aggravated  by  the 
gathering  together  of  a  large  number  of  men  and  cattle,  and  the  insanitary  state 
which  always  accompanies  such  conditions. 

The  history  of  mining  expeditions  also  gives  us  instances  of  the 
transportation  of  typhoid  fever  to  places  far  remote  from  the  perma- 
nent habitations  of  man,  as  is  illustrated  by  the  epidemic  at  Dawson 
City,  on  the  Yukon,  in  January,  1899.  Indeed,  the  history  of  this 
disease  justifies  us  in  stating  that  wherever  and  whenever  men  con- 
gregate and  live  without  adequate  j)rovision  for  disposing  of  their 
excrement,  there  and  then  ty]3hoid  fever  will  appear.  This  seems  to 
be  so  universally^  true  that  manj^  men  who  have  been  engaged  in  the 
study  of  the  epidemiology  of  this  disease  have  come  to  agree  with 
Murchison  in  his  pythogenic  doctrine  concerning  the  origin  of  this 
disease.  This  theory  supposes  that  typhoid  fever  may  be  generated 
independently  of  a  previous  case  by  the  fermentation  of  fecal  and 
other  forms  of  organic  matter.  This  conclusion  results  from  the 
difficulty  generally  experienced  in  tracing  the  introduction  of  the 
disease.  To  this  point  we  have  given  especial  attention  in  our  report^ 
and  we  have  traced  typhoid  fever  into  every  encampment  in  which 
it  became  epidemic  and,  as  already  stated,  man  himself  is  the  most 
active  agent  in  the  dissemination  of  this  disease.  It  is  he  who  carries 
the  specific  virus  about  his  person  into  all  congregations  of  men. 
He  deposits  this  virus  in  his  excrement,  and  it  is  thence  distributed 
in  various  ways  among  his  fellow-men. 

(6)  Dissemination  of  typhoid  fever  through  the  air. 

Is  typhoid  fever  ever  disseminated  through  the  air?  This  is  a  ques- 
tion to  which  diverse  answers  have  been  given.  Our  present  knowl- 
edge of  the  etiology  of  this  disease  gives  no  support  to  the  old  belief 
that  it  may  be  caused  bj^  the  inhalation  of  gases  from  decomposing 
organic  matter.  In  the  first  place,  infection  can  result  only  from  the 
specific  germ,  and  no  amount  of  decomposing  matter  in  which  this> 


215 

organism  is  not  present  can  cause  the  disease.  In  the  second  place, 
the  specific  cause  of  typhoid  fever  is  a  particulate  body  and  not  a 
gas.  Inhalation  of  gases  from  putrid  material  may  cause  intoxica- 
tion, but  not  infection.  Many  of  the  cases  reported  by  older  writers, 
in  which  typhoid  fever  Avas  believed  to  be  due  to  the  inhalation  of 
gases  from  putrid  matter,  were,  as  we  can  now  see,  not  instances  of 
infection.  As  an  illustration  of  this,  we  may  mention  the  Clapham 
epidemic  as  reported  by  Murchison.  Twenty  out  of  twenty-two 
schoolboys,  who  watched  the  oj)ening  of  a  pit  that  contained  a 
large  amount  of  decomposing  organic  matter  and  which  had  been 
closed  for  some  3-ears,  were  within  three  hours  prostrated  with  vomit- 
ing and  diarrhea.  Two  died,  one  within  twenty-three  and  the  other 
within  twenty-five  hours.  Post-mortem  examination  showed  acute 
swelling  of  Peyer's  patches  and  the  solitary  follicles  with  slight  ulcera- 
tion of  these  structures,  together  with  congestion  of  the  mesenteric 
glands.  These  were  diagnosed  as  cases  of  typhoid  fever,  but  we  now 
know  that  they  were  instances  of  acute  poisoning  with  noxious  gases. 
In  the  third  place,  the  tj^phoid  bacillus  is  generally  destroyed  by 
other  germs  or  their  products  in  material  sufficiently  advanced  in 
putrefaction  to  give  off  unpleasant  odors.  The  oldest  cultures  of  the 
bacillus  are  free  from  disagTeeable  smells,  and  infection  with  typhoid 
fever  is  not  likely  to  result  from  ingestion  of  putrid  matter.  Unfor- 
tunately', there  is  nothing  about  food  or  drink  infected  with  this 
germ  to  indicate  to  the  unaided  senses  the  presence  of  such  infection. 
Water  containing  the  typhoid  bacillus  may  be  clear,  sparkling,  and 
of  pleasant  taste.  Milk  infected  with  this  micro-organism  reveals  no 
peculiarities  either  to  taste  or  sight.  A  fly  may  deposit  typhoid  bacilli 
upon  a  cooked  i)otato  without  rendering  this  article  of  food  less  pala- 
table to  the  consumer.  We  wish  to  emphasize  the  difference  between 
the  Ciuestion  now  before  us  as  to  whether  or  not  typhoid  fever  may  be 
disseminated  bj^  infected  particles  of  dust  carried  through  the  air  and 
the  older  idea  that  it  was  spread  by  the  agency  of  gases  given  off 
from  putrid  material.  Such  gases  are  generally  germ  free.  In  fact, 
we  m.8ij  state  as  a  bacteriological  axiom  that  gases  given  off  from 
putrefying  organic  matter  contain  no  germs.  Certainly  this  is  gen- 
eralh'  true,  and  we  know  of  no  exception.  On  the  other  hand,  a  wind 
may  carrj-  x^^rtially  dry  infected  jjarticles  of  dust  which  may  be 
deposited  on  food  or  inhaled  and  cause  typhoid  fever.  However,  we 
are  reaching  a  conclusion  before  stating  arguments.  The  question  is 
whether  or  not  typhoid  fever  ra-dj  be  disseminated  through  the  air. 
Recently,  Germano  has  collected  the  literature  bearing  upon  this 
question  and  has  also  added  experimental  data  of  his  own.  We.  will 
give  a  brief  summary  of  the  statements  made  by  this  author  and  see 
what  conclusions  he  has  drawn  therefrom  and  whether  or  not  we  can 
agree  with  him  in  these  conclusions. 

In  reviewing  the  literature  of  air-borne  typhoid  fever,  Germano 


216 

first  cites  the  article  by  the  Russian  military  surgeon,  Chour,  con- 
cerning the  garrison  at  Jitomir,  to  which  we  have  already  referred. 
We  have  pointed  out  that  Chour's  conclusion  that  the  typhoid  bacil- 
lus was  disseminated  through  the  dust  in  the  rooms  of  the  garrison 
is  not  altogether  justified.  It  may  be  that  th^  bedding  and  clothing 
of  the  soldiers  were  soiled  with  typhoid  stools,  and  the  bacilli  may 
have  been  transported  from  these  soiled  articles  to  the  alimentary 
canal  by  means  of  the  fingers.  Of  course  it  is  possible  that  the  dust 
from  the  infected  clothing,  or  that  deposited  on  the  floor,  walls,  or 
furniture,  did  carry  the  specific  bacillus  through  the  air  which  was 
inhaled  by  the  occupants  of  the  room.  Certainly  it  must  be  admitted 
that  the  report  of  this  epidemic  is  of  value  and  shows  the  necessitj'  of 
the  thorough  disinfection  of  quarters  infected  with  typhoid  fever; 
but  it  does  not  furnish  positive  proof  that  the  infection  was  carried 
through  the  air. 

The  second  citation  bj"  Germano  is  a  report  by  Favier.  On  August 
26,  1886,  a  regiment  of  dragoons  in  which  there  had  been  no  tj^^hoid 
fever,  left  Compiegne  for  the  annual  maneuvers.  From  the  above- 
mentioned  date  until  September  6  of  the  same  year  one-lialf  of  this 
regiment  was  quartered  at  the  village  of  Cuvilly,  while  the  other  half 
was  divided  between  IsTeuville  and  Ressous.  On  the  last-mentioned 
date  the  troops  reunited  at  Compiegne.  On  Sex)tember  11  a  dragoon 
who  had  been  quartered  at  Cuvilly  was  taken  with  typhoid  fever. 
From  this  time  up  to  October  2  of  the  same  year  8  other  cases  ap- 
peared in  this  half  of  the  regiment,  while  onl}'  2  cases  appeared  in 
the  other  half,  and  the  first  of  these  had  its  initial  date  October  5. 
Investigations  show  that  during  the  stay  of  the  troops  at  Cuvilly 
there  were  3  cases  of  tyj)hoid  fever  in  a  family  at  that  place.  The 
soldier  who  first  contracted  typhoid  fever  had  been  quartered  in  this 
house,  and  the  next  2  cases  to  develop  this  disease  were  men  who  had 
visited  this  house.  Fevier  concludes  that  typhoid  fever  was  spread 
in  these  cases  through  the  air.  He  thinks  that  the  man  quartered  in 
the  infected  house  at  Cuvilly  received  the  infection  through  the  air 
inhaled  at  that  place,  and  that  the  soldiers  visiting  this  house  were 
infected  in  the  same  waj^  and  that  the  disease  spread  to  the  half  of 
the  regiment  which  had  not  been  at  Cuvilly  through  the  air.  It  seems 
to  us  that  this  conclusion  is  by  no  means  warranted  in  any  of  these 
cases — at  least  such  a  conclusion  does  not  necessarily  follow  from  the 
facts  as  stated  above.  The  soldier  quartered  at  the  house  of  the  sick 
may  have  been  infected  by  personal  contact  with  tlie  sick,  through 
his  drinking  water  or  through  his  food.  All  of  these  possible  meth- 
ods of  infection  are  also  aj)plicable  to  the  men  who  visited  this  house. 
These  men  may  have  carried  the  infection  in  their  clothing  or  on  their 
persons  to  their  comrades  who  had  not  visited  the  house.  "When  the 
halves  of  the  regiment  were  united-  in  the  common  barracks  at  Com- 
piegne, common  drinking  cups  may  have  become  infected  by  personal 


217 

contact  and  may  account  for  the  spread  of  the  disease.  For  these 
reasons,  we  are  inclined  to  reject  this  report  as  evidence  that  typhoid 
infection  may  be  disseminated  through  the  air. 

The  third  report  cited  by  Germane  is  equallj^  unsatisfactory.  Olli- 
vier  states  that  a  girl  sick  Avith  typhoid  fever  was  placed  in  a  hospital 
ward  in  which  there  were  no  other  cases  of  this  disease.  Soon  there- 
after two  other  patients  in  the  same  ward  developed  typhoid  fever. 
One  of  these  occupied  the  bed  by  the  side  of  the  first  x)atient  and  the 
other  a  bed  opposite.  In  order  to  prevent  further  dissemination  of 
the  disease,  the  ward  was  vacated  and  thoroughly  disinfected.  The 
disinfection  of  the  ward  was  certainlj^  justified,  but  the  conclusion 
that  the  disease  was  spread  through  the  air  is  by  no  means  warranted. 
It  is  more  than  i^robable  that  attendants  carried  the  germs  on  soiled 
fingers  from  one  patient  to  the  other.  The  history  of  these  cases 
teaches,  as  similar  instances  likewise  indicate,  that  it  is  not  safe  to 
place  typhoid-fever  patients  in  a  ward  occupied  hy  those  suffering 
from  other  diseases;  or,  in  other  words,  it  teaches  the  desirability  of 
the  isolation  of  tyi3hoid  cases,  but  certainly  it  furnishes  no  positive 
proof  that  typhoid  fever  may  be  disseminated  through  the  air. 

LecuA^er  describes  a  small  epidemic  of  typhoid  fever  in  Vassognes, 
in  which  village  there  had  not  been  a  case  of  this  disease  for  several 
years.  The  corpse  of  a  woman  who  had  died  from  typhoid  fever  at 
Rheims  was  brought  to  Vassognes  for  burial.  The  body  had  not  been 
embalmed  and  was  transported  in  a  simple  wooden  coffin  and  at  the 
time  of  burial  was  in  an  advanced  stage  of  decomposition.  A  few 
daj  later,  three  children  of  the  dead  woman  came  from  Rheims  to  Vas- 
sognes. These  soon  sickened  with  typhoid  fever,  and  the  disease 
spread  until  it  had  infected  many  other  persons  in  the  village.  The 
author  concludes  from  the  fact  that  Vassognes  had  long  been  free 
from  typhoid  that  the  germs  were  disseminated  through  the  air.  His 
conclusion  that  the  water  of  the  village  was  not  the  source  of  infection 
is  justified,  but  his  belief  that  the  disease  was  spread  through  the  air 
is  only  an  assumption.  Soiled  hands  and  clothing  were  more  likely 
factors  in  the  spread  of  the  infection. 

Dewolz  rej)orts  certain  cases  that  occurred  at  Eaux  Bonnes.  In 
Jul}',  1886,  a  woman  from  Paris  came  to  a  hotel  in  this  village,  where 
she  soon  developed  tj'phoid  fever.  The  disease  ran  a  normal  course, 
and  terminated  after  four  weeks  in  recovery.  A  short  time  after 
this,  three  daughters  of  the  proprietor  of  the  hotel  were  taken  sick 
with  typhoid  fever.  Beyond  these  cases  the  epidemic  did  not  spread. 
Before  the  coming  of  tlie  woman  from  Paris  there  had  been  no  case 
of  typhoid  fever  in  tlie  village.  Bacteriological  examination  of  the 
drinking-water  suppl}^  shoAved  it  to  be  of  unquestionable  purity.  The 
air  of  the  room  occupied  by  the  girls  communicated  through  a  covered 
passage  with  that  of  the  sick  chamber  of  the  woman.  Moreover,  the 
door  of  the  privy  in  Avhich  the  dejections  of  the  sick  woman  Avere 


218 

tlirown,  without  disinfection,  opened  into  the  same  passage.  The 
anthor  concludes  that  the  disease  germs  were  carried  through  the  air. 
This  conclusion  does  not  necessarily  follow.  It  may  have  been  that 
those  attending  the  sick  woman  handled  the  food  of  the  children  with- 
out disinfecting  their  hands. 

Passing  over  a  number  of  other  reports  collected  in  the  review  of 
the  literature  by  Germano,  we  come  to  that  of  Froidboise.  The  mili- 
tary station  of  St.  Bernard  lies  about  2  miles  south  of  Antwerp  and 
1,800  meters  from  the  point  where  the  Rupel  flows  into  the  Schelde. 
Usually  there  are  four  regiments  of  infantry  located  at  this  place. 
For  three  years  there  had  not  been  a  case  of  typhoid  fever  among  the 
soldiers  in  these  barracks,  when  in  August,  1892,  a  severe  epidemic 
appeared.  The  initial  date  of  the  first  case  was  August  22  and  of  the 
last  case  October  20.  The  water  supply  was  not  changed  nor  were 
the  barracks  disinfected.  The  explanation  given  by  Froidboise  is  as 
follows :  On  account  of  some  engineering  work  which  was  being  done 
in  the  Schelde  at  the  mouth  of  the  Rupel,  the  latter  stream  overflowed 
its  left  bank  and  distributed  a  large  amount  of  sewage  brought  down 
from  Brussels  and  Mechlin.  The  receding  water  left  a  thin  deposit 
scattered  over  several  thousand  acres  of  land.  As  this  deposit  con- 
sisted of  sewage  from  Brussels  and  Mechlin,  it  is  more  than  likely 
that  it  contained  the  typhoid  bacillus  in  large  numbers.  As  has  been 
stated,  the  epidemic  began  August  22  and  ended  October  20.  From 
August  12  until  October  10  the  direction  of  the  prevailing  wind  was 
such  that  it  would  carry  the  dust  from  the  drying  deposit  toward  and 
into  the  garrison.  Before  and  after  the  dates  mentioned  above,  the 
wind  was  in  the  opposite  direction.  It  seems  to  us  that  this  is  the 
most  interesting  report  among  those  collected  from  medical  literature 
by  Germano.  As  has  been  stated,  the  water  supply  to  the  soldiers  in 
the  barracks  was  not  changed  before,  during,  or  after  the  epidemic. 
Neither  could  the  disappearance  of  the  disease  be  attributed  to  disin- 
fection, because  this  was  not  practiced.  The  question  is  whether  or 
not  the  typhoid  bacillus  can  be  carried  in  particles  of  dust  suspended 
in  .the  air  through  a  distance  of  1,800  meters.  Germano  concludes 
that  this  is  impossible,  but  we  will  return  to  this  question  later. 

Germano  quite  properly  divides  the  above-mentioned  and  similar 
reports  collected  hj  himself  into  three  groups.  In  the  first  group  he 
places  those  instances  in  which  it  was  probable  that  the  disease  was 
disseminated  by  direct  contact  with  the  sick,  leading  to  soiling  of  the 
hands  or  clothing  with  the  infected  dejections.  In  the  second  group, 
he  thinks  that  indirect  contact  through  persons  with  soiled  hands  or 
through  infected  clothing  or  bedding  or  other  agents  is  a  more  likelj^ 
explanation  than  dissemination  through  the  air.  As  an  instance  of 
cases  coming  in  the  second  group  we  will  give  one  reported  hy  Gielt. 
A  man  while  away  from  home  contracted  typhoid  fever  and  returned 
to  his  native  village,  in  which  there  had  not  been  a  case  of  this  dis- 


219 

ease  for  a  long  while.  The  undisinfected  feces  from  this  man  were 
thrown  upon  a  dung  heap.  Some  weeks  later  5  men  carted  away  this 
material  and  later  4  of  these  developed  tj^phoid  fever  and  the  fifth 
suffered  from  intestinal  catarrh,  accompanied  by  enlargement  of  the 
spleen.  The  undisinfected  dejections  from  these  men  were  thrown 
upon  another  dung-heap.  A  few  months  later  2  men  removed  this 
material,  and  of  these  1  developed  typhoid  fever.  Brouardel,  who 
reported  these  cases  for  Gielt,  supposes  that  the  typhoid  bacilli  were 
disseminated  through  the  air  from  decomposing  dung  heaps.  Ger- 
mano  thinks  it  more  probable  that  the  men  engaged  in  this  work 
soiled  their  hands  and  in  this  way  transferred  the  bacilli  to  their 
mouths.  This  is  highly  probable,  but  certainly  we  can  not  positively 
state  that  particles  of  dust  were  not  inhaled  by  the  men  who  were 
engaged  in  loading  and  unloading  the  infected  material.  In  order  to 
arrive  at  £mj  opinion  concerning  the  probability  between  the  possible 
avenues  of  infection  in  these  cases,  we  would  have  to  know  more  than 
we  do  concerning  the  amount  of  moisture  in  the  material  when  it  was 
removed  and  the  strength  of  the  wind  prevailing  at  the  time.  In  the 
third  group  Germano  places  those  cases  in  which  the  germs  are  sup- 
posed to  be  disseminated  through  the  air,  because  no  other  explana- 
tion seems  probable;  but  he  states  that  in  many  epidemiological 
investigations  the  cause  of  the  spread  of  the  disease  remains  unknown, 
because  we  can  not  ascertain  all  the  conditions. 

After  reviewing  the  literature  as  stated  above,  Germano  endeavors 
to  decide  the  question  cor^cerning  the  jDOssible  dissemination  of 
typhoid  bacilli  through  the  air  experimentally.  In  his  investigations 
he  finds  that  typhoid  bacilli  mixed  with  dust  from  different  sources 
and  thoroughly  desiccated  speedily  dies,  and  he  concludes  that  air 
infection  through  many  hundred  meters,  as  supposed  by  Froidboise 
in  the  cases  that  occurred  in  the  military  garrison  near  Antwerp,  is 
impossible.  In  our  opinion  Germano's  experiments  confirm  what  was 
already  well  known,  that  the  typhoid  bacillus  is  speedily  deprived  of 
life  by  desiccation,  but  they  do  not  convince  us  that  dissemination  of 
the  living  germ  in  particles  of  partially  dried  dust  may  not  be  carried 
even  distances  of  several  hundred  meters  and  deposited  upon  the 
food,  in  the  drinking  water,  or  inhaled. 

More  recently,  Neisser  has  shown  that  dust  infected  with  the  typhoid 
bacillus  may  be  carried  by  a  current  of  air  moving  at  a  rate  of  1.7 
centimeters  per  second  through  a  distance  of  680  centimeters  and 
there  deposited  with  the  germ,  still  possessed  of  vitality.  However,- 
he  concludes  that  since  this  germ  is  not  transported  to  a  distance  of 
more  than  680  centimeters  by  the  air  moving  at  a  rate  which  gen- 
erally prevails  within  a  room,  that  typhoid  fever  can  not  be  considered 
a  dust  disease,  but  is  nearly  so.  It  will  be  seen  that  this  conclusion 
has  reference  only  to  the  possibility  of  the  typhoid  bacillus  floating 
through  the  air  of  a  closed  room ;  but  even  within  doors  the  air  often 


220 

moves  with  a  velocity  many  times  greater  than  1.7  centimeters  per 
second.  Especially  is  this  true  when  the  movement  of  the  air  within 
the  room  is  influenced  by  drafts  from  windows,  doors,  and  ventilating 
flues.  Thus  we  find  that  there  is  a  iDOSsibility  of  typhoid  infection 
from  the  inhalation  of  the  air  of  a  room  in  the  dust  of  which  the  spe- 
cific bacillus  of  this  disease  exists.  Partially  dried  typhoid  stools  on 
the  floor  may  be  sufficiently  comminuted  to  form  an  infected  dust, 
which  may  float  through  the  air,  be  deposited  on  food,  find  its 
way  into  uncovered  receptacles  of  water  or  milk,  or  be  directly 
inhaled,  find  lodgment  in  the  nose  and  pharynx,  and  finally  reach 
the  intestines. 

While  all  of  this  is  possible  within  a  closed  room,  the  danger  of 
air  infection  with  tj^phoid  fever  must  be  greatlj^  increased  in  military 
life,  where  food  and  drink  are  often  exposed  for  hours  to  an  atmos- 
phere laden  with  dust,  possibly  infected  with  the  tyi:)hoid  bacillus. 
As  we  shall  have  occasion  to  state  later,  the  surface  of  the  ground 
about  many  of  the  regimental  encampments  at  Chickamauga  in  1898 
was  so  covered  witli  fecal  matter  that  it  was  imiDOSsible  to  walk 
through  those  places  without  soiling  the  feet.  So  prevalent  was 
typhoid  fever  at  Chickamauga  that  much  of  this  fecal  matter  must 
have  contained  the  Eberth  bacillus,  and  it  seems  hardlj^  possible  that 
the  great  clouds  of  dust  in  which  the  men  lived  could  have  been  free 
from  this  infection.  The  shell  roads  through  the  encampments  at 
Jacksonville  were  ground  by  the  heavy  army  wagons  into  an  impal- 
pable dust  several  inches  thick.  Along  these  roads  scavengers  carted 
in  half  barrels  fecal  matter  containing  the  typhoid  bacillus.  The 
contents  of  these  tubs  frequently  splashed  over  and  fell  in  this  dust. 
On  each  side  of  these  roads  soldiers  were  encamped,  and  manj-  mess 
tables  were  in  close  proximit}"  to  the  roads.  Local  whirlwinds  some- 
times caught  up  large  quantities  of  this  dust  and  carried  it  consider- 
able distances.  After  seeing  these  things,  we  feel  that  we  can  not 
exclude  the  dust  as  a  probable  carrier  of  the  typhoid  infection,  not- 
withstanding the  fact  that  it  would  probably  be  a  very  difficult  thing 
to  scientifically  demonstrate  that  the  disease  was  disseminated  in 
this  wa3^ 

(c)  The  influence  of  the  soil  in  the  dissemination  of  typhoid  fever. 

There  is  an  old  and  wides]3read  belief  tliat  many  of  our  ills  come 
from  the  soil,  and  man  has  always  been  inclined  to  attribute  his  mis- 
fortunes to  localitj'.  That  this  idea  has  not  disappeared  is  shown  by 
the  fact  that  many  of  the  soldiers  encamped  at  Chickamauga  in  1898 
repeated  the  storj^that  the  name  of  the  place  is  an  Indian  word  mean- 
ing "river  of  death,"  and  that  the  locality  Avas  naturally  an  unhealthy 
one.  Furthermore,  that  some  of  the  surgeons  shared  in  this  belief  in 
the  special  virulence  of  the  locality  was  evidenced  by  the  fact  that 
they  designated  the  continued  fevers  that  developed  among  the  soldiers 
as  "Chickamauga  fever,"  and  claimed  that  it  was  different  in  many 


221 

respects  from  any  fever  known  elsewhere.  Of  course,  it  is  true  that 
there  are  unhealthful  localities,  but  the  most  salubrious  place  can  be 
rendered  unfit  for  human  habitation  when  soiled  by  the  excretions 
of  man.  As  we  shall  see  later,  the  surface  of  Chickamauga  Park 
did  become  largelj^  contaminated,  and  the  locality  certainly  was,  in 
the  late  summer  of  1898,  an  unhealthy  one,  but  this  was  not  due  to 
natural  conditions,  and  there  is  not  the  slightest  evidence  that  the 
soil  of  this  locality  is  naturally  productive  of  typhoid  fever.  Had 
the  same  troops  been  encamped  in  the  most  healthful  spot  in  the 
world,  and  had  they  shown  the  same  disregard  of  camp  sanitation, 
there  is  no  reason  for  believing  that  they  would  have  fared  any  better 
than  they  did  in  Chickamauga  Park,  which  is  in  truth  naturally  a 
most  salubrious  locality. 

There  is  an  old  theory  concerning  the  relation  of  the  soil  to  the 
causation  of  typhoid  fever  which  still  has  many  advocates.  This 
theorj^  supposes  that  decomposing  organic  matter  in  the  soil  passes 
through  a  ripening  process  by  means  of  which  the  typhoid  poison  is 
either  generated  de  novo  or  is  greatly  increased  in  virulence.  Refer- 
ence has  already  been  made  to  the  pythogenic  theorj^  of  Murchison, 
and  this,  in  a  more  or  less  modified  form,  has  been  accepted  and  is 
advocated  by  many  prominent  epidemiologists,  especially  those  with 
military  experience.  It  is  believed  that  diiferent  soils  vary  in  their 
adaptability  to  harbor,  grow,  and  ripen  this  poison.  The  believers  in 
the  pythogenic  doctrine  are  divided  into  two  groups:  (1)  Those  who 
hold  that  soil  contaminated  with  any  fecal  matter  will  generate  the 
typhoid  poison;  (2)  those  who  believe  that  the  introduction  of  the 
specific  bacillus  is  necessary,  but  that  this  undergoes  a  ripening  pro- 
cess in  the  soil  by  means  of  which  its  virulence  is  greatly  augmented. 

Scientific  support  of  the  theory  of  the  rijDening  of  the  typhoid  poison 
in  the  soil  has  been  found  by  the  investigations  of  Pettenkofer  into 
the  etiology  of  typhoid  fever  in  Munich.  During  the  first  half  of  the 
present  century  typhoid  fever  was  continuously^  endemic  in  Munich. 
This  city  is  situated  on  a  bed  of  gravel  and  marl,  and  during  the  time 
mentioned  fecal  matter  was  deposited  in  pits  and  allowed  to  percolate 
into  the  soil  from  which  the  drinking  water,  collected  in  shallow  wells 
and  surface  springs,  was  taken.  With  our  present  knowledge  of  the 
etiology  of  this  disease  we  would  suppose,  with  the  above-mentioned 
conditions  existing,  that  the  drinking  water  was  specifically  contami- 
nated. However,  Pettenkofer,  from  his  ver}^  careful  studies  of  the 
distribution  of  the  disease,  came  to  the  conclusion  that  its  prevalence 
was  not  due  to  contaminated  water.  After  many  years  of  careful 
and  skillful  investigation,  he  found  that  the  prevalence  of  typhoid 
fever  varied  inversel}^  with  the  height  of  the  ground  water  under 
the  cit3^  The  nearer  the  ground  water  came  to  the  surface,  the  less 
tj^phoid  fever;  with  the  fall  of  the  level  of  the  ground  water  the 
number  of  cases  of  typhoid  fever  increased.     He  concluded  from  this 


222 

that  the  deeper  layers  of  the  soil  contained  iDutrefactive  material  in 
which  the  typhoid-fever  poison  undergoes  a  ripening  process,  and 
that  the  ripened  germ  passes  from  the  soil  into  the  air  and  is  inhaled 
bj'  susceptible  persons.  When  the  level  of  the  ground  water  is  high, 
the  putrefying  material  in  which  the  ripening  process  is  supposed  to 
be  going  on  is  covered  by  the  water  and  its  escape  into  the  air  is 
IDrevented,  while  a  fall  in  the  ground  water  leaves  the  putrefjdng 
substances  uncovered  and  the  poison  jiasses  into  the  air.  It  will  be 
seen  from  these  statements  that  Pettenkofer  believes  that  the  spe- 
cific poison  must  be  present,  but  that  this  undergoes  in  the  soil 
changes  by  means  of  which  its  virulence  is  augmented.  If  this  the- 
orj^  be  true,  it  should  hold  good  for  other  cities  as  well  as  for  Munich, 
and  numerous  investigators  have  found  that  elsewhere  this  supposed 
relation  between  ground  water  and  the  prevalence  of  typhoid  fever 
is  by  no  means  constant.  Indeed,  thei-e  are  so  many  exceptions  to 
Pettenkofer's  rule  concerning  this  relationship  between  the  level  of 
ground  water  and  the  prevalence  of  typhoid  fever  that  this  theory 
must  be  abandoned  as  an  exj3lanation  of  the  origin  of  epidemics  of 
typhoid  fever.  There  is  no  reason  for  believing  that  in  the  ordinary 
movements  of  the  air  from  the  pores  in  the  ground  to  the  atmo- 
sphere the  velocitj^  is  sufficient  to  carry  dust  laden  with  bacilli. 
Certainly,  such  a  transference  of  the  bacillus  from  the  deeper  layers 
of  the  soil  to  the  atmosphere  in  the  form  of  dust  must  be  of  most 
exceptional  occurrence,  if  it  ever  happens.  It  might  be  stated  in  this 
connection  that  some  sanitarians  accept  that  part  of  Pettenkofer's 
theory  which  provides  for  the  ripening  of  the  poison  in  the  soil,  but 
believe  that  the  ripened  and  highly  virulent  bacillus  finds  its  way 
into  the  drinking  water  and  does  not  infect  through  the  air. 

(fZ)  The  dissemination  of  typhoid  fever  through  drinking  water. 

There  can  be  but  little  doubt  that  in  civil  life  the  great  epidemics 
of  typhoid  fever  are  generallj'  caused  by  the  specific  contamination 
of  drinking  water.  The  danger  in  infected  water  was  recognized  long 
before  the  discovery  of  the  specific  bacillus  and,  indeed,  epidemics 
had  been  unquestionably  traced  to  contaminated  water  supplies.  We 
have  already  seen  that  this  micro-organism  may  live  and  multiplj^  in 
water.  The  most  frequent  contamination  of  drinking  water  with 
typhoid  material  results  from  the  introduction  into  the  water  of  the 
feces  or  urine  of  some  infected  j)erson.  After  this  has  happened,  the 
rapid  multiplication  of  the  organism  in  water  permits  the  speedy  infec- 
tion of  a  large  volume.  Moreover,  in  flowing  water  the  specific  bacil- 
lus may  be  carried  considerable  distances.  Variations  in  the  tempera- 
ture of  this  medium  do  not  affect  the  virulence  of  the  germ.  It  may 
be  frozen  in  ice  and  remain  in  this  condition  quite  indefinitely  with- 
out any  loss  in  potency,  and  it  is  equallj^  unaffected  by  alternate 
freezing  and  thawing.  The  specific  contamioation  of  drinking  water 
may  be  responsible  for  isolated  cases  and  for  both  small  and  large 


223 

epidemics.  The  infection  of  a  farm  well  may  lead  to  one  or  more 
cases,  according  to  the  number  of  susceptible  people  who  drink  from 
this  source.  Village  epidemics  may  be  due  to  contamination  of  the 
public  water  supply  or  that  of  some  popular  well  or  spring.  In  large 
cities  epidemics  involving  hundreds  and  possibly  thousands  of  cases 
may  result  from  the  contamination  of  the  water  sui3ply  at  some  point 
nearby  or  distant,  as  the  case  may  be,  from  the  city. 

The  fact  that  typhoid  fever  is  frequently  disseminated  through 
drinking  water  is  so  well  known  that  it  is  not  necessary  to  take  up 
much  space  in  giving  instances.  The  epidemic  at  Plymouth,  Pa. ,  in 
1885,  investigated  by  a  member  of  this  board,  may  be  brieflj'  referred 
to.  At  that  time  the  population  of  Plymouth  numbered  about  9,000. 
The  epidemic  appeared  suddenly,  a  maximum  of  200  cases  being 
reported  in  one  day.  Within  a  short  time  one-ninth  of  the  population 
had  been  stricken  with  the  disease.  It  was  soon  discovered  that 
typhoid  fever  appeared  only  in  those  houses  which  were  connected 
with  the  general  water  suj^ply  of  the  town.  Houses  whose  inmates 
confined  themselves  to  wells  for  their  drinking  water  wholly  escaped 
the  disease.  Thus  it  happened  that  in  some  parts  of  the  city  typhoid 
fever  was  present  in  nearly  every  house  on  one  side  of  the  street  and 
did  not  occur  in  any  house  on  the  other  side.  The  water  supply  of 
the  town  was  obtained  from  a  number  of  reservoirs  fed  by  a  mountain 
stream.  On  the  bank  of  this  stream,  between  two  of  the  reservoirs, 
was  a  house  in  which  there  had  been  shortly  before  the  outbreak  of 
the  epidemic  a  case  of  typhoid  fever.  This  man  visited  Philadelphia 
late  in  December,  1884,  and  while  there  contracted  typhoid  fever. 
He  returned  to  his  home  in  January,  1885,  and  during  his  illness, 
which  continued  for  manj'  weeks,  the  undisinfected  dejecta  were 
thrown  upon  the  snow  within  a  few  feet  of  the  stream,  or  emptied 
into  a  privy  standing  on  the  hillside  near  the  bank  of  the  stream. 
Late  in  March  the  melting  snow  washed  this  infected  material  into 
the  water  supply  and  the  first  cases  in  the  village  appeared  within 
three  weeks  of  this  time. 

The  epidemic  at  Iron  Mountain,  Mich.,  in  1887,  investigated  by 
another  member  of  this  board,  furnishes  some  interesting  points.  At 
that  time  the  population  of  Iron  Mountain  numbered  about  6,000,  con- 
sisting principally  of  miners.  There  were,  all  told,  in  the  place  about 
1,000  houses,  many  of  the  dwellings  being  small  and  crowded.  The 
village  is  situated  in  a  valley  extending  north  and  south,  and  the 
lowest  portion  occupies  a  localitj^  which  was  originally  swampy.  Upon 
each  side  of  this  village  the  hills  are  steep,  and  the  greater  part  of  the 
town  lies  upon  the  eastern  slope.  The  soil  is  drift,  consisting  of  sand 
and  gravel,  except  in  the  lowest  portions  of  the  valley,  where  the  drift 
is  overlaid  with  vegetable  mold.  In  some  places  the  ledge  of  rock, 
which  is  of  the  Huronian  strata,  outcrops  on  the  hilltops;  in  others, 
on  the  hillsides,  and  in  others,  in  the  valley.     The  drift  is  so  porous 


224 

tliat  within  twenty-four  hours  after  hea^-y  rains  the  surface  is  dry.  A 
portion  of  the  village,  numbering  about  300  houses,  had  at  that  time  a 
system  of  water  supply,  the  source  of  which  was  a  shaft  40  feet  deep 
and  far  away  from  the  contamination,  to  be  referred  to  later.  Those 
who  drank  exclusivelj-  of  water  from  this  source  wholly  escaped  typhoid 
fever.  The  remaining  portion  of  the  callage,  the  part  in  which  fever 
prevailed,  obtained  its  drinking  water  from  wells  sunk  from  6  to  20 
feet  deep.  There  were  no  sewers  or  other  means  of  removing  filth. 
Privy  vaults  were  used  and  slops  and  garbage  were  thrown  into  back 
yards  and  into  the  streets.  A  ditch,  which  conveyed  the  water  from 
a  mine  to  a  small  lake  beyond  the  village,  ran  through  this  part  of  the 
town  and  was  used  hj  many  as  an  open  sewer.  During  the  early 
summer  of  1S87  this  portion  of  the  village  was  exceedingly  filthy;  but 
notwithstanding  this  fact  there  were  absolutely  no  cases  of  typhoid 
fever.  In  July  a  man  sick  with  this  disease  was  brought  from  a  rail- 
road construction  camp  to  the  village  and  placed  in  one  of  the  houses 
highest  up  the  hill,  where  he  remained  till  he  died.  The  undisin- 
fected  dejections  from  this  man  were  thrown  upon  the  ground  about 
the  house  and  into  a  privj^  vault  in  the  yard.  Rains  evidently  washed 
this  material  into  the  wells  farther  down  the  hill.  In  August  a  severe 
epidemic  of  typhoid  fever  appeared,  and  350  cases  were  soon  reported. 
In  one  house  13  of  the  inmates  were  striken  with  typhoid  fever  almost 
simultaneously.  It  should  have  been  stated  that  although  this  \allage 
was  exceedingly  filthy  in  1886,  there  was  no  case  of  typhoid  fever 
during  that  year.  The  history  of  this  epidemic  indicates  that  filth, 
unless  it  be  specifically  contaminated,  will  not  cause  typhoid  fever. 

It  is  not  always  easy  to  determine  how  typhoid  fever  finds  its  way 
into  a  community.  Indeed,  it  frequently  happens  that  an  epidemic 
of  this  disease  breaks  out  in  some  isolated  neighborhood  without  any 
evidence  of  its  being  brought  into  the  place.  Cases  of  this  kind  have 
led  some  to  suppose  that  typhoid  fever  may  originate  de  novo  or  that 
the  colon  bacillus  present  in  normal  feces  may  take  on  a  specially 
Airulent  form,  in  which  condition  it  may  develop  typhoid  fever.  The 
possibility  of  the  conversion  of  the  colon  bacillus  into  the  typhoid 
germ  has  been  discussed  elsewhere.  It  will  only  be  necessary  to  state 
here  that  there  are  so  many  possible  ways  in  which  t j-phoid  fever  may 
find  its  way  into  almost  any  locality  that  it  is  not  necessary  to  resort 
to  any  improbable  theory  in  order  to  explain  its  occurrence  at  unex- 
pected places.  AVe  have  in  mind  an  epidemic  investigated  by  one  of 
us  a  few  years  ago  which  may  serve  as  an  illustration.  The  \allage 
of  St.  Clair,  Mich.,  a  place  of  about  1,500  inhabitants,  is  located  on 
the  St.  Clair  River,  and  during  the  winter  time  is  connected  with  the 
outside  world  by  a  spur  from  a  railroad  a  few  miles  distant  from  the 
village.  During  the  summer  time  St.  Clair,  on  account  of  its  loca- 
tion and  its  mineral  waters,  has  its  population  multiplied  several 
times,  but  after  the  close  of  navigation  the  number  of  strangers  com- 


225 

iiig  to  tlie  place  is  small.  In  the  spring  of  1887  a  most  violent  ei^i- 
demic  of  typhoid  fever  suddenly  burst  out  in  this  village.  Within  a 
few  weeks  more  than  300  cases  were  reported.  The  village  had  its 
water  supply  from  the  St.  Clair  River,  and  the  intake  pipe  extended 
out  several  hundred  feet  into  the  channel.  A  few  private  sewers  or 
drains  emptied  into  the  river  above  the  intake  pipe,  but  the  extension 
of  the  pipe  far  out  into  the  channel,  it  was  supposed,  avoided  any 
contamination  from  these  sources.  The  most  careful  inquiry  failed 
to  give  any  history  of  an  imported  case  of  typhoid  fever.  That  the 
disease  was  spread  through  the  village  by  means  of  the  drinking  water 
did  not  admit  of  doubt.  Only  those  who  took  their  water  from  the 
village  supply  had  the  disease.  Moreover,  several  farmers  who  came 
to  town  and  drank  of  the  village  water  developed  the  disease,  while 
those  members  of  their  families  who  had  not  visited  St.  Clair  remained 
unaffected.  It  was  so  plainly  evident  that  the  water  was  contaminated 
that  the  authorities  determined  to  extend  the  intake  pipe  farther  out 
into  the  river  across  a  sandbar  and  to  take  the  supply  from  the  Cana- 
dian channel,  but  in  preparing  for  this  work  it  was  found  that  the 
intake  pipe  was  broken  off  near  the  shore  and  that  the  water  was 
directly  contaminated  from  the  private  drains  mentioned  above. 
There  had  been  no  case  of  typhoid  fever  in  the  houses  from  which 
tliese  drains  came.  As  soon  as  the  pipe  was  extended  and  the  water 
supply  taken  from  the  middle  of  the  river  the  epidemic  disai)peared 
as  suddenly  as  it  had  begun. 

It  might  be  inferred  from  this  history,  which  is  by  no  means  unique, 
that  pollution  of  the  drinking  water  with  normal  fecal  matter,  or  at 
least  with  that  which  did  not  contain  the  typhoid  bacillus,  caused  the 
epidemic.  However,  this  conclusion  is  not  necessary.  It  is  altogether 
possible  for  an  individual  to  carry  in  his  alimentary  canal  and  elim- 
inate therefrom  the  Eberth  bacillus  in  virulent  form  without  having 
the  disease  himself.  The  probabilities  are  that  the  majority  of  men 
who  reach  40  years  of  age  have  at  some  time  or  another  carried  this 
germ  in  their  bodies,  and  this  may  account  for  the  fact  that  men  of 
this  age  are  less  susceptible  to  the  disease  than  younger  men.  It  is 
also  possible  in  the  St.  Clair  epidemic  that  the  infection  came  down 
the  river  from  Port  Huron,  about  12  miles  distant.  Another  possible 
explanation  might  be  given  by  supposing  that  an  individual  who  had 
recovered  from  typhoid  fever  recently,  in  visiting  one  of  the  houses 
above  the  intake  discharged  from  his  body  into  the  drains  the  specific 
bacillus  of  typhoid  fever.  In  some  instances  the  typhoid  bacillus  con- 
tinues to  be  eliminated. with  the  urine  for  several  weeks  after  recovery 
from  this  disease,  and  each  cubic  centimeter  of  such  urine  may  contain 
millions  of  virulent  bacilli.  We  say  that  these  are  possible  explana- 
tions, and  as  long  as  we  have  no  experimental  evidence  that  the  colon 
bacillus  is  ever  converted  into  the  typhoid  germ,  and  inasmuch  as  we 
7273 — —15 


226 

do  not  know  of  such,  conversion  among  other  micro-organisms,  we  are 
justified  in  thinking  that  such  explanations  as  those  suggested  above 
are  not  to  be  overlooked. 

From  the  statements  already  made  it  must  be  recognized  that  it  is 
never  safe  to  drink  water  contaminated,  or  which  may  possibly  be 
contaminated,  with  human  excrement,  even  when  this  comes  exclu- 
sively from  healthy  people.  We  do  not  mean  to  say  that  water  thus 
contaminated  would  always  cause  typhoid  fever.  In  fact  we  have 
already  given  evidence  that  such  water  may  be  taken  for  a  long  time 
without  giving  rise  to  this  disease,  but  there  is  always  the  possibility 
that  even  healthy  persons  may  carry  in  their  bodies  for  a  while  and 
then  eliminate  the  typhoid  bacillus  in  virulent  form. 

The  question  is  sometimes  asked  whether  or  not  the  presence  of  the 
colon  bacillus  in  water  should  condemn  its  use.  We  are  not  prepared 
at  present  to  answer  this  question  categorically.  There  are  undoubt- 
edly^ many  varieties  of  the  colon  bacillus,  and  these  not  onlj'^  differ  in 
virulence,  but  come  from  diverse  sources.  A  colon  bacillus  is  found  in 
the  excretions  of  certain  aquatic  animals,  and  it  is  not  probable  that  a 
few  of  these  would  injure  man  in  any  way.  However,  at  present  we 
can  not  distinguish  between  colon  bacilli  from  turtles  and  fishes  and 
those  from  man.  Furthermore,  we  have  no  reason  for  believing  that 
colon  bacilli  from  man  would  cause  typhoid  fever,  but  the  presence  of 
this  germ  indicates  contamination  of  the  water  supply  with  human 
excrement,  and  this  condition  is  always  dangerous  to  health  and  life. 
Even  when  the  typhoid  bacillus  is  present  in  water  the  colon  bacterium 
is  usually  also  present,  and  in  such  large  numbers  that  the  isolation 
and  identification  of  the  Eberth  bacillus  is  exceedingly  difficult. 

There  is  danger  of  using  an  infected  water  in  washing  the  hands, 
face,  and  other  parts  of  the  body.  One  of  this  board  had  an  experi- 
ence a  few  years  ago  illustrating  this  point.  A  certain  family  received 
its  drinking-water  supplj^  from  the  city  pipes,  but  as  this  water  was 
slightly  hard  the  members  of  the  family  used  for  ablution  a  soft  water 
from  a  cistern,  Avhich  was  known  to  be  wholly  unfit  for  drinking  pur- 
poses. The  family  consisted  of  father  and  mother,  two  sons  and  two 
daughters  ranging  in  age  from  14  to  21,  and  two  roomers,  young  men 
of  about  20  years  of  age.  Every  member  of  this  household,  except 
the  father  and  mother,  came  down  one  after  the  other  with  typhoid 
fever  at  a  time  when  there  was  not  another  case  among  more  than 
12,000  people  using  the  same  general  water  supply.  That  this  house- 
hold epidemic  was  due  to  the  infected  cistern  water,  supposed  to  be 
used  only  for  ablution,  there  can  scarcelj^  be  unj  doubt.  As  has  been 
stated,  this  water  was  exceedingly  impure,  and  bacteriological  exam- 
ination showed  the  presence  in  large  numbers  of  a  certain  variety  of 
the  colon  bacillus.  One  of  those  infected  with  typhoid  fever  in  this 
household  stated  that  she  had  occasionally  used  the  soft  water  for 
washing  her  teeth;  two  others  had  used  it  in  giving  themselves  treat- 


227 

ment  by  means  of  a  nasal  douch  for  catarrh ;  while  the  others  did  not 
remember  having  used  the  water  except  for  washing  the  face  and 
hands. 

Another  very  striking  illustration  of  the  danger  of  using  an  infected 
water  for  any  purpose  was  furnished  during  the  epidemic  at  St.  Clair, 
Mich.,  already  referred  to.  At  the  earliest  appearance  of  the  epi- 
demic at  this  place,  a  very  intelligent  family  residing  there  decided 
to  use  every  precaution  possible  against  infection.  Carbonated  table 
water  was  used  exclusively  for  drinking  purposes.  The  epidemic  had 
nearly  passed,  and  this  family,  remaining  free  from  infection,  was 
congratulating  itself,  when  one  of  its  members  was  stricken  with  the 
disease.  When  interrogated  by  her  physician,  this  patient  remem- 
bered that  she  had  always  washed  her  teeth  in  the  bathroom  and  had 
used  the  infected  water  for  this  purpose.  These  and  other  similar 
illustrations  show  the  danger  that  there  is  in  using  an  infected  water 
for  any  purpose. 

It  should  be  borne  in  mind  that  foods  and  drinks  diluted  with  water 
infected  with  the  typhoid  bacillus  may  not  only  carry  the  poison,  but 
may  serve  as  suitable  media  for  its  growth.  The  spread  of  typhoid 
fever  by  the  milkman  has  been  quite  frequently  observed.  One  of 
us  investigated  an  epidemic  of  this  kind  a  few  years  ago.  In  a  vil- 
lage of  2,000  people  there  were  about  30  cases  of  typhoid  fever.  All  of 
these  were  in  families  supplied  by  a  certain  milkman  who  lived  some 
distance  in  the  country.  Investigation  showed  that  this  man  had 
recently  had  2  cases  of  typhoid  fever  in  his  family. 

The  typhoid  bacillus  will  retain  its  vitality  in  milk  for  thirty  days 
or  longer,  or  until  it  is  destroyed  by  the  growth  of  other  organisms. 
It  should  be  remembered  that  a  given  sample  of  milk  may  become 
infected  after  it  has  been  boiled  or  otherwise  sterilized.  In  our  exam- 
ination and  inspection  of  army  hospitals,  we  sometimes  found  hospi- 
tal stewards  who  believed  that  they  had  done  their  whole  duty  when 
they  supplied  sterilized  milk,  and  they  did  not  exercise  care  necessary 
to  keep  flies  from  infecting  the  sterilized  milk.  The  germ  of  typhoid 
fever  will  grow  quite  as  rapidly  and  abundantly  in  sterilized  as  in  raw 
milk.  If  sterilization  is  to  be  followed  by  subsequent  infection,  there 
can  be  no  advantage  in  practicing  sterilization.  The  specific  germ  of 
typhoid  fever  will  not  only  grow  in  milk,  but  will  continue  to  preserve 
its  vitality  in  certain  milk  products.  It  will  live  in  butter  for  thirty 
days  or  longer.  Its  vitality  in  cheese  is  determined  by  a  number  of 
conditions.  In  so-called  cottage  cheese,  the  typhoid  bacilli  may 
retain  its  vitality  for  several  days,  and  this  may  serve  as  a  means  of 
infection. 

The  possibility  of  infecting  drinking  water  by  means  of  impure  ice 
should  not  be  overlooked.  Experiments  have  shown  that  so  far  as 
bacteria  are  concerned,  water  does  not  by  any  means  wholly  purify 
itself  in  freezing,  and  ice  may  be  the  bearer  of  the  typhoid  infection. 


228 

Undoubtedly  it  has  sometimes  happened  that  a  perfectly  pure  drink- 
ing water  has  been  contaminated  by  impure  ice. 

There  is  a  somewhat  prevalent  belief  that  the  dilution  of  infected 
water  with  alcoholic  drinks  renders  the  chances  of  infection  less. 
This  belief  has  no  scientific  support.  It  is  true  that  undiluted  brandy 
or  whisky  will  destroy  the  bacillus  within  a  few  minutes,  but  in  either 
of  these  drinks  diluted  with  an  equal  volume  of  water  the  typhoid 
bacillus  may  retain  its  vitality  for  at  least  a  half  an  hour.  The  germ 
may  live  for  some  time  in  all  kinds  of  wine ;  white  and  red,  sweet  and 
sour,  and  in  ales  and  beer. 

So-called  soft  drinks,  which  were  extensively  sold  to  soldiers  in  the 
various  national  encampments  in  1898,  probably  had  something  to  do 
with  the  spread  of  tj-phoid  fever.  Venders  of  such  preparations  were 
not  at  all  particular  as  to  the  source  of  the  water  used  in  their  manu- 
facture, and  if  it  happened  to  be  infected,  so  much  the  worse  for  the 
consumers.  Certainly,  efforts  to  prevent  typhoid  fever  in  encamp- 
ments can  never  be  successful  until  the  medical  officer  has  under  his 
control  every  possible  means  for  the  spread  of  the  disease.  If  soldiers 
must  have  either  alcoholic  or  so-called  soft  drinks,  they  should  be  fur- 
nished in  a  regular  canteen  under  the  supervision  of  the  medical  offi- 
cers of  the  command. 

Vegetables  and  fruits,  especiallj^  those  eaten  raw,  may  carrj^  the 
typhoid  infection.  For  instance,  the  leaves  of  lettuce  maj^  become 
infected  with  typhoid  stools  while  still  in  growth,  or  they  may  be 
sprinkled  with  infected  water  by  the  farmer  who  markets  them  or  the 
green  grocer  who  sells  them. 

It  has  been  suggested. that  the  milk  of  cows  drinking  infected  w^ater 
may  contain  the  specific  germ  of  typhoid  fever.  There  is  no  proba- 
bility that  the  Eberth  bacillus  taken  into  the  stomach  of  a  cow  would 
reappear  in  the  milk  of  the  same  animal,  but  it  is  possible  that  this 
germ  might  be  eliminated  in  the  feces  of  the  cow  and  in  the  form  of 
dust  may  find  its  way  into  the  milk.  We  know  that  nearly  every 
sample  of  cow's  milk  sold  in  the  market  contains  the  colon  bacillus, 
which  owes  its  presence  in  the  milk  not  to  passage  through  the  milk 
glands,  but  contamination  of  the  milk  with  the  fecal  matter  of  the  cow. 

Investigations  made  by  Conn  and  Broadbent  indicate  that  oysters 
grown  in  water  infected  with  typhoid  fever  may  serve  as  carriers  of 
the  specific  infection.  It  is  uncertain  whether  the  infection  results 
from  taking  some  infected  water  in  which  the  oyster  lives  along  with 
the  animal  or  from  the  bacillus  incorporated  in  the  body  of  the  moUusk. 

(e)  Transportation  of  the  bacillus  on  the  person  or  in  clothing. 

That  the  infection  of  typhoid  fever  is  often  carried  on  the  hands  or 
in  the  clothing  of  nurses  and  other  attendants  there  can  scarcely  be 
any  doubt.  This  is  probably  one  of  the  chief  means  by  which  the 
disease  is  spread  through  a  f amilj''  after  its  introduction.  The  mother 
or  other  attendant  on  the  sick  handles  the  food  of  the  well  without 


229 

disinfection  of  the  hands.  Superficial  ablution  with  soap  and  water 
is  not  sufficient  to  destroy  the  vitality  of  this  organism ;  thorough  dis- 
infection, with  special  attention  to  the  material  collected  under  the 
finger  nails,  is  absolutely  essential.  At  one  of  the  division  hospitals 
at  Camp  Alger  in  August,  1898,  the  members  of  this  board  observed 
the  nurses,  many  of  whom  went  directly  from  their  duties  in  the 
typhoid  wards  to  their  mess  tents  and  handled  the  food  eaten  by 
themselves  and  passed  articles  to  their  neighbors  without  even  wash- 
ing their  hands.  Another  practice  for  which  superior  officers  were 
responsible  is  undoubtedly  accountable  to  a  greater  or  less  extent  for 
the  spread  of  typhoid  fever  among  the  soldiers  at  the  various  encamp- 
ments in  1898:  It  was  customary  in  some  of  the  commands  to  take  a 
fresh  detail  of  men  from  the  line  each  day  as  orderlies  at  the  hospital. 
Each  morning  100  men  were  detailed  to  attend  those  sick  with 
typhoid  fever,  to  place  and  adjust  bedpans,  and  to  carry  the  contents 
of  these  to  the  sinks  and  to  disinfect  them.  These  men,  at  least  the 
majority  of  them,  were  wholly  ignorant  of  the  nature  of  infection; 
they  had  never  had  any  training  as  nurses;  they  knew  nothing  about 
the  desirability  or  necessity  of  being  careful  in  order  to  prevent 
infecting  themselves,  and  they  knew  less  about  means  of  disinfecting 
their  hands  soiled  witli  typhoid  discharges.  At  the  close  of  the  day 
these  men  were  returned  to  their  company  tents,  and  the  next  morn- 
ing a  new  detail  of  the  same  number  went  through  with  the  same 
routine.  A  more  effective  means  for  the  spread  of  typhoid  fever 
could  scarcely  have  been  devised. 

Many  of  the  so-called  cases  of  prolonged  incubation  after  exposure 
to  typhoid  fever  can  be  best  explained  by  the  supposition  that  the 
infective  material  is  carried  on  the  person  some  time  before  it  finds 
its  way  into  the  alimentary  canal.  We  shall  have  occasion  further  on 
to  mention  some  of  these  cases.  However,  it  may  be  stated  here  that 
undoubtedly  a  man  may  carry  the  typhoid  bacillus  under  his  finger 
nails,  in  his  hair,  or  on  his  clothing  for  weeks,  during  which  time  he 
may  travel  across  the  continent,  and  at  last  accidentally  introduce 
the  germ  into  his  alimentary  canal  and  develop  the  disease.  Some 
authorities  la}'  much  stress  upon  the  period  of  incubation  in  the  infec- 
tious diseases,  and  the  International  Sanitary  Conference,  which  has 
attempted  to  prevent  the  spread  of  the  plague  from  India,  has  based 
its  most  important  measures  upon  what  is  supposed  to  be  the  maxi- 
mum period  of  incubation  of  the  disease.  It  must  be  evident  that  we 
know  very  little  about  the  true  period  of  incubation  in  most  of  the 
infectious  diseases.  If  a  hospital  corps  man  who  has  been  attending 
typhoid  patients  at  Ponce,  Porto  Rico,  leaves  that  place  on  a  certain 
date,  does  not  come  in  contact  with  other  typhoid  patients,  and  ten 
weeks  later  develops  the  disease,  this  certainly  does  not  prove  that  the 
period  of  incubation  in  typhoid  fever  may  be  extended  to  ten  weeks. 
This  man  may  have  carried  the  specific  germ  on  his  person  or  in  his 


230 

clothing  for  the  first  eight  out  of  the  ten  weeks  and  then  accidentally 
introduced  it  into  his  alimentary  canal.  The  fact  that  a  belief  in  ten 
days  as  the  maximum  period  of  incubation  in  the  plague  has  been 
the  cause  of  the  introduction  of  that  disease  from  India  into  Europe 
should  cause  us  to  hesitate  about  laying  too  much  stress  upon  so-called 
periods  of  incubation.  The  period  of  incubation  of  an  infectious  dis- 
ease is  the  time  which  elapses  from  the  introduction  of  the  germ  into 
the  body  until  the  development  of  the  first  symptoms  of  the  disease, 
and  unless  we  know  definitely  and  positively  the  day  or  the  hour  of 
the  introduction  of  the  germ  into  the  body,  we  can  not  determine  the 
period  of  incubation.  The  number  of  days,  weeks,  or  months  the 
patient  has  carried  the  germ  in  his  clothing  has  nothing  to  do  with 
the  period  of  incubation. 

Experimental  evidence  shows  that  pure  cultures  of  typhoid  fever 
bacilli  will  retain  their  virulence  when  poured  upon  cotton,  linen,  or 
woolen  cloth  for  from  two  to  three  months,  and  it  is  altogether  pos- 
sible that  the  infection  may  be  carried  in  a  blanket  roll  for  a  much 
longer  time.  The  evidence  which  we  will  bring  forward  in  connection 
with  the  history  of  typhoid  fever  in  our  Armj^  during  the  late  war 
with  Spain  will  show  quite  conclusively,  we  think,  that  infected 
clothing,  bedding,  and  tentage  had  much  to  do  with  the  spread  of 
typhoid  fever  and  will  demonstrate  the  necessity  in  attempting  to 
eradicate  this  disease  from  an  infected  command  of  disinfecting  all 
the  above-mentioned  articles. 

The  personal  and  bed  linen  of  patients  sick  with  typhoid  fever 
when  soiled  with  discharges  from  the  kidneys  or  bowels  should  be 
immediately  immersed  in  a  properly  prepared  disinfecting  solution. 
When  such  articles  are  thrown  aside  without  previous  disinfection, 
flies  may  carry  the  infection  from  the  stains  to  articles  of  food,  and, 
moreover,  after  the  material  dries,  handling  these  articles  may  scatter 
the  infective  material  through  the  air  in  the  form  of  fine  dust. 

(/)  Dissemination  by  flies. 

We  are  satisfied  that  the  evidence  furnished  in  our  studies,  to  be 
detailed  later,  is  sufficient  to  show  beyond  reasonable  doubt  that  the 
most  active  agents  in  the  spread  of  typhoid  fever  in  many  of  the 
encampments  in  1898  were  flies.  The  reason  for  coming  to  this  con- 
clusion will  be  given  in  detail  later,  but  may  be  summed  up  here  as 
follows : 

(1)  The  latrines  contained  fecal  matter  specifically  infected  with 
the  typhoid  bacillus. 

(2)  Flies  alternate^  visited  and  fed  upon  this  infected  fecal  matter 
and  the  food  in  the  mess  tents.  More  than  once  it  happened  when 
lime  had  been  scattered  over  the  fecal  matter  in  the  pits,  files  with 
their  feet  covered  with  lime  were  seen  walking  over  the  food. 

(3)  Typhoid  fever  was  much  less  frequent  among  members  of 
messes  Avho  had  their  mess  tents  screened  than  it  was  among  those 
who  took  no  such  precaution. 


231 

(4)  Typhoid  fever  gradually  died  out  in  the  fall  of  1898  in  the 
encampments  at  Knoxville  and  Meade  with  the  disappearance  of  the 
fly,  and  this  occurred  at  a  time  of  the  year  when  in  civil  practice 
typhoid  fever  is  generally  on  the  increase.  We  will  take  the  encamp- 
ment at  Knoxville  as  a  special  object  of  study  in  this  inquiry. 
Most  of  the  regiments  at  Knoxville  came  from  Chickamauga,  where 
they  had  become  seriously  infected  with  typhoid  fever.  The  specific 
germ  of  this  disease  was  carried  from  Chickamauga  to  Knoxville  in 
the  bodies  of  the  men,  on  their  persons,  in  their  clothing,  in  their 
blankets,  and  in  their  tents.  The  first  pits  at  Knoxville  contained 
before  the  first  twenty-four  hours  had  passed  after  the  arrival  of  the 
troops  fecal  matter  infected  with  the  typhoid  bacillus.  Flies  swarmed 
everywhere.  Instead  of  abating,  the  disease  increased.  The  soldiers 
were  using  the  same  water  used  exclusively  by  the  inhabitants  of 
West  Knoxville,  and  among  the  latter  there  was  not  at  that  time  a 
case  of  typhoid  fever.  Certainly  the  disease  was  not  disseminated 
through  the  drinking  water.  The  locations  of  the  regimental  camps 
were  ideal.  The  ground  had  never  been  occupied  by  troops  before, 
consequently  was  not  polluted,  but  as  has  been  stated,  typhoid  fever 
continued  to  increase  until  the  cooler  weather  of  October  lessened  the 
number  of  flies  and  simultaneously  typhoid  fever  diminished.  It  has 
been  suggested  that  typhoid  fever  gradually  disappeared  among  these 
troops  because  all  the  susceptible  material  had  been  used  up.  For- 
tunately, we  can  give  a  definite  answer  to  this  suggestion.  The  divi- 
sion at  Knoxville  received  several  regiments  of  recently  recruited 
troops  who  had  not  been  at  Chickamauga.  These  regiments  arrived 
early  in  September.  They  soon  were  infected  with  typhoid  fever,  but 
the  disease  disappeared  among  these  new  regiments  simultaneously 
with  its  disappearance  among  the  older  troops.  Certainly  it  can  not 
be  said  that  the  disappearance  of  the  disease  among  these  recently 
recruited  regiments  was  due  to  the  exhaustion  of  susceptible  material. 

Flies  may  carry  infected  matter  from  the  persons  of  those  sick  with 
the  disease  and  deposit  it  in  the  drink  or  on  the  food  of  the  healthy. 
To  those  who  have  seen  flies  feeding  upon  the  fecal  matter  smeared 
over  the  buttocks  of  patients  or  have  seen  them  crawling  into  the 
mouths  of  the  unconscious  typhoid  subject,  nothing  more  is  necessary 
than  to  mention  this  possible  means  of  the  dissemination  of  the  dis- 
ease. When  flies  abound,  the  man  sick  with  typhoid  fever  should  be 
protected  from  the  annoyance  of  this  insect,  not  only  because  the 
patient  will  be  more  comfortable,  but  this  protection  is  desirable  in 
order  to  prevent  the  spread  of  the  disease  through  the  agency  of  these 
pests. 

Flies  may  carry  the  infected  material  from  soiled  clothing  or  bed- 
ding and  deposit  it  upon  food.  We  have  already  mentioned  this  fact 
and  have  recommended  that  soiled  personal  and  bed  linen  be  immedi- 
ately immersed  in  a  disinfecting  solution. 

Near  the  rear  end  of  one  of  the  regimental  hospitals  inspected  by 


232 

ns  we  found  a  half  dozen  or  more  bed  pans,  all  more  or  less  soiled 
with  stools  undisinfected,  swarming  with  flies,  which  may  have  visited 
the  mess  tents  later.  No  undisinfected  material  should  be  left  exposed 
to  the  flies. 

CONDITIONS   INFLUENCING  THE  SPREAD    OF  TYPHOID   FEVER. 

The  prevalence  of  typhoid  fever  is  apparently  influenced  largely  by 
season.  This  certainly  is  true  in  the  north  temperate  zone,  both  in 
Europe  and  America.  It  is  most  prevalent  during  late  summer  and 
the  fall  and  is  least  prevalent  during  the  spring  months.  As  a  rule 
the  increase  in  frequency  begins  to  be  observable  in  Julj^  and  con- 
tinues, according  to  the  season  and  local  conditions,  to  increase 
until  the  last  of  October  or  November.  In  December,  as  a  rule,  the 
decrease  in  frequency  is  noticeable  and  continues  until  the  minimum 
is  reached  in  March,  April,  and  May.  The  researches  of  Flint,  "Wood, 
and  others  showed  this  to  be  true  in  the  United  States  soon  after  the 
medical  profession  learned  to  distinguish  between  typhus  and  typhoid 
fevers,  and  more  recent  authorities  in  this  country  have  confirmed 
this  observation.  Curschmann,  Fiedler,  and  others  find  the  same  to 
be  true  in  Germany,  and  Murchison,  in  his  classical  studies  of  tj'^phoid 
fever,  showed  that  season  has  a  like  effect  on  the  prevalence  of  this 
disease  in  Great  Britain. 

While  it  is  probably  generally  true  that  typhoid  fever  is  most  prev- 
alent in  the  fall,  great  epidemics  of  this  disease  do  not  always  occur 
at  this  season  of  the  year.  In  fact,  the  greater  prevalence  of  typhoid 
fever  in  the  fall  of  the  year  is  not  so  marked  now  as  it  was  thirty  years 
ago,  because  of  the  altered  conditions  under  which  we  live.  This  rela- 
tionship has  always  been  more  evident  in  a  rural  than  in  an  urban 
population.  At  present  the  most  striking  epidemics  of  typhoid  fever 
are  those  that  occur  in  cities  and  are  due  to  an  infected  water  sup- 
ply. Season  affects  these  epidemics  to  the  extent  to  which  it  modi- 
fies the  chances  of  water  infection.  Many  of  these  epidemics  within 
recent  years  have  occurred  in  the  spring  of  the  year,  during  the  months 
in  which,  according  to  the  general  rule,  the  prevalence  of  typhoid 
fever  should  be  at  a  minimum.  Water  infection  is  likely  to  occur 
when  the  snow  melts  and  the  ice  breaks  up,  and  is  due  to  infected 
material  deposited  on  the  surface  during  the  winter.  As  we  have 
already  seen,  the  epidemic  at  Plymouth,  Pa.,  was  accounted  for  in 
this  way;  another  of  the  epidemics  already  referred  to,  that  at  St- 
Clair,  Mich.,  occurred  in  March  and  April.  Epidemics  of  typhoid 
fever  due  to  an  infected  water  supply  are  quite  independent  of  season, 
except  as  stated  above.  On  the  other  hand,  epidemics  due  to  insects 
and  those  caused  by  the  dissemination  of  the  germ  in  the  form  of  dust 
are  more  likely  to  occur  during  late  summer  and  autumn.  The  same 
is  probably  true  of  some  ejjidemics  in  rural  places  due  to  infected 
wells.     Contaminated  material  is  more  widely  disseminated  in  sum- 


233 

mer  and  fall  than  during  any  other  season  of  the  year.  In  the  sum- 
mer time  or  in  the  early  fall  a  typhoid  stool  thrown  on  the  surface  of 
the  ground  maj^  be  scattered  far  and  wide  by  the  wind;  may  be  car- 
ried on  the  feet  of  men  and  animals;  may  be  washed  into  wells  or 
springs,  and,  in  short,  its  wide  dissemination  is  more  likely  to  occur 
at  this  season  of  the  year  than  at  any  other.  These  facts,  in  our 
opinion,  sufficiently  explain  the  relation  between  typhoid  fever  and 
season  so  far  as  such  a  relation  exists. 

INFLUENCE   OF   AGE   ON   TYPHOID   FEVER. 

That  typhoid  fever  is  much  more  likely  to  occur  in  persons  of  a  cer- 
tain age  than  in  others  younger  or  older  is  shown  by  voluminous 
statistical  evidence.  However,  we  must  not  be  too  hasty  in  arriving 
at  conclusions  on  this  point.  First,  we  will  give  the  general  state- 
ments and  will  then  briefly  discuss  the  same. 

Curschraann  states: 

Undoubtedly  early  adult  life  especially  predisposes  the  individual  to  typhoid 
fever.  Individuals  from  lo  to  35  years  of  age  are  in  greatest  danger  of  this  dis- 
ease. In  my  experience  at  least  four-fifths  of  all  cases  have  occurred  among 
people  within  these  limits,  and  more  than  half  (about  56  per  cent)  have  been 
between  15  and  25  years  of  age.  Between  30  and  35  years  the  per  cent  begins  to 
fall,  and  from  35  to  40  it  sinks  rapidly.  After  the  fiftieth  year  the  per  cent  of  mor- 
bidity from  this  disease  falls  to  a  fraction.  In  old  age  typhoid  fever  is  seldom 
seen.  During  the  first  year  of  life,  as  is  the  case  with  most  infectious  diseases, 
typhoid  fever  is  rare.  From  the  first  to  the  fifth  year  morbidity  from  this  dis- 
ease increases.  From  the  fifth  to  the  fifteenth  year  the  disposition  to  typhoid 
fever  is  increased  and  is  greater  than  it  is  during  the  period  from  35  to  40  years. 

Murchison  reported  52  per  cent  of  his  cases  among  individuals 
from  15  to  25  years  of  age.  Fiedler  found  58.8  per  cent  of  his  cases 
to  range  from  20  to  30  years  of  age,  while  onty  3.4  were  over  40  and 
0. 7  per  cent  over  50. 

While  percentages  of  morbidity  and  mortalitj^  do  not  always  cor- 
respond, the  following  figures  from  a  table  prepared  by  Brouardel, 
giving  the  ages  of  those  dying  from  typhoid  fever  in  Paris  from  1880 
to  1889,  undoubtedl}'  gives  a  correct  idea  of  the  relative  prevalence 
of  this  disease  in  persons  of  different  ages.  This  table  is  of  value  on 
account  of  the  large  number  of  cases  upon  which  it  is  founded,  the 
number  amounting  to  16,036. 

Deaths  from  typhoid  fever  in  Paris  from  1880  to  1889. 

Up  to  1  year 36     30  to  35  years 1, 197 

1  to  5  years 1,041     35  to  40  years --. 771 

5  to  10  years 1 , 265     40  to  45  years 457 

lOto  15  years ..-     1,386  :  45  to  50  years 380 

15to20years 2,991  j  After  50  years 583 

20  to  25  years 8,896                                                                   

25to30years  2,081  |              Total 16.036 

This  apparent  predisposition  of  early  manhood  to  typhoid  fever 
may  be  partially  exi^lained.     In  the  first  place,  it  is  at  this  time  of 


234 

life  that  man  roves  about  most,  obtaining  his  water  and  food  from 
the  most  diverse  sources,  and  it  must  be  evident  that  his  chances  of 
infection  are  greater  than  they  are  earlier  or  later  in  life.  In  the 
second  place,  it  is  possible  that  many  of  those  who  have  reached  40 
years  of  age  have  acquired  a  certain  immunity  to  the  disease  without 
ever  having  developed  it  in  recognizable  form.  The  evidence  that 
we  shall  give  later  that  short  diarrheas  often  give  at  least  temporary 
immunity  to  typhoid  fever  has  been,  to'  us  at  least,  quite  convincing. 
How  long  this  immunity  may  continue  in  different  individuals  we 
have  no  means  of  determining.  The  infant  taking  his  nourishment 
exclusively  from  his  mother's  breast  has  but  little  opportunity  of 
being  infected  with  typhoid  fever.  As  he  grows  up  and  seeks  his 
food  and  drink  from  other  sources,  the  danger  of  typhoid  fever  infec- 
tion increases  in  direct  proportion  to  the  diversity  of  the  sources  from 
which  he  draws  his  supply.  During  the  period  of  life  when  he  mingles 
most  largel}'  and  most  promiscuously  with  other  men,  the  danger  of 
infection  is  increased.  Later  in  life  he  becomes  tethered  by  his  habits. 
He  visits  fewer  places,  cares  less  for  the  society  of  strangers,  and  the 
chances  of  infection  are  decreased.  While  sickness  from  typhoid  fever 
is  much  more  frequent  in  early  manhood,  the  per  cent  of  deaths  among 
cases  is  much  greater  late  in  life.  In  general,  other  things  being  equal, 
the  per  cent  of  mortality  increases  with  advancing  years  and  ranges 
from  2  per  cent  in  early  childhood  to  more  than  50  per  cent  in  old  age. 
The  mortality  in  persons  from  15  to  35  years  of  age  averages  about  7.5 
per  cent,  but  of  course  varies  considerably  in  different  outbreaks  and 
is  modified  to  some  extent  by  the  individual  condition  of  patients. 

THE    IXFLUEXCE   OF   SEX. 

Hospital  statistics  taken  alone  indicate  that  typhoid  fever  is  more 
prevalent  among  men  than  among  women.  However,  this  is  not  true, 
and  the  apparent  greater  prevalence  among  men  as  shown  by  hospital 
figures  is  due  to  the  fact  that  more  men  than  women  are  treated  in 
hospitals.  Moreover,  all  hospital  statistics  do  not  show  a  greater  per 
cent  of  cases  among  men.  In  London  from  1848  to  1861,  according 
to  Murchison,  2,432  cases  of  typhoid  fever  were  treated  in  the  fever 
hospital;  of  these,  1,211  were  males  and  1,221  were  females.  There  is 
not  the  slightest  reason  for  believing  that  sex  has  any  influence 
ujjon  susceptibility  to  typhoid  fever.  It  is  probably  true  that  on  a 
whole  a  larger  number  of  men  than  women  have  the  disease,  but  this 
is  due  to  the  fact  that  men  are  more  frequently  exposed  to  infection ; 
they  travel  about  more;  they  take  their  food  and  drink  from  more 
diverse  sources,  and  consequently  the  chances  of  infection  are  greater. 

Pregnancy  and  the  puerperal  state  apparently  give  some  degree  of 
temporary  immunity  to  typhoid  fever,  or  at  least  decrease  the  sus- 
ceptibility to  this  disease.     Curschmann  states: 

Griesinger  finds  typhoid  fever  to  be  very  rare  in  the  puerperal  state,  and 
believes  that  nursing  mothers  are  especially  protected  against  this  disease;  in  this 


235 

he  agrees  with  Rokitansky,  and  I  myself  have  only  twice  seen  typhoid  fever  appear 
among  women  in  the  puerperal  state  and  very  seldom  during  lactation. 

Pregnancy  is  also  supposed  to  lessen  susceptibility  to  this  disease. 
However,  the  probabilities  are  that  the  relatively  small  number  of 
cases  observed  among  women  during  pregnancy  and  the  puerperal 
condition  is  due  to  the  fact  that  during  these  periods  women  are  less 
exposed  to  infection  than  at  other  times. 

rNFLUENCE   OF   FATIGUE. 

Bodily  fatigue  and  mental  worry  apparently  increase  susceptibility 
to  typhoid  fever.  The  effect  of  fatigue  is  especially  observable  in 
armies.  However,  there  are  certain  points  connected  with  the  study 
of  this  subject  that  are  not  altogether  clear,  and  there  is  a  possibility 
of  falling  into  error  in  formulating  conclusions  concerning  the  rela- 
tion between  fatigue  and  tj^phoid  fever.  In  the  first  place,  exhaustive 
phj^sical  exertion,  as  is  instanced  after  prolonged  forced  marches  with 
raw  troops,  may  cause  a  continued  fever  which  resembles  typhoid 
fever  clinically,  but  is  wholly  different  in  its  etiology  and  pathology. 
This  fever  of  exhaustion  may  continue  for  two  or  three  weeks  and 
may  be  mistaken  for  typhoid  fever.  However,  it  never  occurs  in 
epidemic  form.  It  has  been  observed  that  within  two  or  three  days 
after  a  forced  march  or  other  exhaustive  exercises  the  number  of 
typhoid-fever  cases  increases.  The  short  time  elapsing  between  the 
exercise  and  the  appearance  of  the  fever  does  not  justify  the  belief 
that  infection  occurred  during  or  after  the  exercise,  but  in  many  of 
these  cases  infection  must  have  occurred  before  the  physical  exer- 
cise, and  the  only  effect  attributable  to  this  is  that  of  causing  the 
more  speedy  development  of  the  disease  in  persons  already  infected. 
It  is  true  that  physical  exhaustion  may  and  probably  does  increase 
susceptibility  to  typhoid  fever;  this  probably  is  brought  about  by 
lowering  the  resivStance  of  the  body  against  an  infection. 

INFLUENCE   OF   SOCIAL,   POSITION. 

Typhoid  fever  is  not  more  prevalent  among  the  poor  than  among 
the  rich.  Indeed,  it  frequently  prevails  more  extensively  among  the 
better-to-do  classes  than  among  those  suffering  from  poverty.  It  was 
frequently  told  us  while  making  our  inspection  of  the  camps  that 
companies  recruited  from  the  wealthier  classes  had  more  typhoid 
fever  than  those  from  the  working  classes.  This  may  be  due  to  the 
fact  that  these  men,  having  more  money  to  spend,  indulged  more 
largely  in  purchases  from  venders  of  articles  of  food  likely  to  be 
infected.  This  subject  will  be  referred  to  again  in  the  body  of  our 
report.  In  civil  practice  also  it  is  observable  that  typhoid  fever  is 
not  a  disease  of  poverty,  but,  on  the  other  hand,  it  is  more  likely  to 
afflict  those  who  are  pecuniarly  well-to-do.  Furthermore,  this  disease 
is  more  prevalent  among  the  well-nourished,  apparently  healthy  and 


236 

robust  than  it  is  among  the  more  delicate.  We  have  already  seen 
that  man  is  most  susceptible  to  this  disease  in  early  adult  life,  when 
he  is  supposed  to  be  possessed  of  the  greatest  vitalit3^  The  full- 
blooded,  vigorous  man  is  quite  as  likely  to  fall  a  victim  of  this  dis- 
ease as  his  anaemic  weak  brother.  So  far  as  the  influence  of  vocation 
is  concerned  there  is  no  evidence  that  one  occupation  more  than 
another  creates  a  special  disposition  to  this  disease,  except  when  the 
occupation  brings  the  individual  into  more  frequent  and  dangerous 
communication  with  the  bacillus.  Physicians,  nurses,  and  laun- 
dresses show  a  large  x)er  cent  of  typhoid  fever,  but  this  is  due  to  the 
fact  that  their  work  brings  them  into  close  contact  with  the  stools  of 
typhoid-fever  patients.  Other  callings  may  place  men  so  that  they 
are  more  likelj"  to  drink  t}-phoid-inf ected  water.  It  is  for  this  reason 
that  dock  hands,  stevedores,  and  sailors  show  a  large  percentage  of 
typhoid  fever. 

I^-FLUE^X'E   OF  EXPOSURE   TO   COLD. 

It  is  quite  widely  believed  that  exposure  to  cold  increases  suscepti- 
bility to  t^-phoid  fever.  In  most  reported  cases  supposed  to  illustrate 
this  point  the  fever  follows  so  closely  upon  the  exposure  that  the 
infection  must  have  occurred  previously.  The  probabilities  are  that 
in  most  of  these  cases  the  sujDposed  exposure  to  cold  was  due  to  the 
chilly  sensations  likely  to  accompany  the  prodromal  stage  of  this 
disease. 

INFLUENCE   OF   OTHER   DISEASES. 

The  influence  of  other  diseases  u]3on  susceptibility  to  typhoid  infec- 
tion is  interesting,  but  is  also  one  about  which  we  must  be  slow  to 
draw  conclusions,  because  the  evidence  is  likely  to  be  misleading. 
Curschmann  states  that  the  acute  infectious  diseases,  especiall}^  dur- 
ing the  febrile  stage,  protect  against  infection  with  tj^phoid  fever. 
He  also  has  observed  that  during  convalescence  from  other  acute 
infectious  diseases  there  seems  to  be  partial  and  temporary  immunity 
to  tj-phoid  fever.  These  opinions  are  based  upon  jjersonal  observa- 
tions in  several  great  epidemics,  notabl}^  that  of  Hamburg  from  1885 
to  1888,  in  which  15,804  cases  were  reported.  However,  we  must  bear 
in  mind  that  one  sick  with  scarlet  fever  or  some  other  acute  infectious 
disease  is  not  for  the  time  being  exposed  to  tyjihoid  infection  to  the 
same  extent  that  healthy  people  are.  The  Hamburg  epidemic  was 
due  to  an  infected  water  supply,  and  it  is  more  than  likeh"  that  indi- 
viduals suffering  at  that  time  from  other  acute  infectious  diseases 
drank  proi)ortionately  less  unboiled  water  than  others  did.  However, 
there  may  be  truth  in  Curschmann's  observations;  we  simply  suggest 
caution  in  accepting  them  as  conclusive.  The  fact  that  malaria  and 
typhoid  fever  may  simultaneously  exist  in  the  same  individual  will 
be  discussed  later;  and  Curschmann  himself  states  that  he  has  seen 
along  the  Rhiue  malaria  and  tj-phoid  fever  prevalent  in  one  i)lace  at 


237 

the  same  time,  but  he  makes  no  mention  of  the  coexistence  of  this  dis- 
ease in  the  same  individual.  The  same  great  clinical  teacher  has 
observed  that  persons  with  tuberculosis  in  an  advanced  stage  seldom 
become  infected  with  typhoid  fever,  notwithstanding  the  fact  that 
tuberculous  patients  are  often  kept  for  long  periods  in  the  same  hos- 
pital wards  with  tj^phoid-fever  cases.  He  thinks,  however,  that  in 
these  cases  the  immunity  to  typhoid  fever  should  be  chiefly  attributed 
to  the  emaciations  accompanying  tuberculosis;  and  he  states  that 
typhoid  fever  is  also  rare  among  those  suffering  from  malignant  dis- 
eases, from  constitutional  diseases,  especially  from  diabetes.  His 
belief  that  the  immunity  to  typhoid  fever  observed  in  advanced  cases 
of  tuberculosis  is  due  to  the  emaciations  rather  than  to  specific  infec- 
tion with  the  tubercle  bacillus  is  supported  by  the  observation  that 
individuals  with  latent  tuberculosis  fail  to  show  this  immunity  to 
typhoid  fever,  and  he  adds  that  every  physician  of  large  experience 
has  unfortunately  had  opportunity  to  observe  the  rapid  progress  of 
tuberculosis  in  such  cases  during  illness  with  typhoid  fever.  He 
states  that  individuals  suffering  from  chronic  nervous  diseases,  in  so 
far  as  those  maladies  occur  among  those  of  susceptible  age,  show  no 
immunity  to  tj^phoid  fever. 

The  relation  of  preexistent  diseases  of  the  stomach  and  intestines 
to  susceptibility  to  typhoid  fever  is  an  interesting  one.  On  this  point 
we  make  the  following  quotation  from  Curschmann: 

The  assertion  that  errors  in  diet,  with  consequent  gastric  and  intestinal  catarrh, 
induce  typhoid  fever  is  no  longer  open  to  discussion.  This  formerly  accepted  view 
was  founded  upon  false  conclusions  drawn  from  different  observations  in  accord- 
ance with  the  differently  accepted  ideas  concerning  the  etiology  of  the  disease.  It 
undoubtedly  happened  that  the  early  symptoms  of  typhoid  fever  were  often  con- 
founded with  those  of  simple  gastro- intestinal  catarrh;  especially  is  this  likely  to 
occur  in  typhus  ambulans  when  the  true  nature  of  the  disease  is  often  not  recog- 
nized until  a  chilly  febrile  relapse  compels  the  individual  to  seek  his  bed.  On  the 
other  hand,  it  is  conceivable  that  errors  in  diet,  with  their  consequences,  may  favor 
the  development  of  the  contagion,  and  it  is  not  improbable  that  in  individuals 
already  infected  they  may  hasten  the  appearance  of  the  disease.  This  view  is  sup- 
ported by  the  frequently  observed  fact  that  relapses  follow  dietetic  errors.  The 
supposed  susceptibility  to  typhoid  fever  after  acute  and  chronic  diseases  of  the 
stomach  has  been  attributed  to  the  altered  production  of  hydrochloric  acid.  From 
experiments  made  outside  of  the  body  upon  other  pathogenic  germs  which  infect 
by  way  of  the  intestinal  tract,  this  assumption  appears  probable,  and  although 
the  typhoid  bacillus  is  relatively  more  resistent  to  the  action  of  the  gastric  juice 
than  the  other  pathogenic  micro-organisms,  it  is  not  to  be  doubted  that  marked 
diminution  of  the  free  hydrochloric  acid  does  materially  improve  the  chances  of 
this  germ  passing  uninjured  into  the  intestines.  Theoretically,  on  the  other  hand, 
although  we  have  no  practical  evidence  bearing  on  the  subject,  it  might  be  assumed 
that  gastric  affections  accompanied  by  hyperacidity  protect  against  typhoid  fever. 

Certainly,  with  our  present  knowledge  concerning  the  etiology  of 
typhoid  fever,  no  one  will  hold  that  this  disease  is  ever  caused  by 
errors  in  diet  or  by  the  consequent  gastric  and  intestinal  catarrh. 
However,  there  still  remains  the  question  whether  or  not  catarrhal 


238 

conditions  of  tlie  stomacli  and  intestines  place  these  organs  in  a  better 
condition  for  tlie  reception  and  retention  of  the  typhoid  bacillus.  The 
members  of  this  board  began  this  investigation,  all  believing  that 
especial  attention  should  be  given  to  the  study  of  the  relation  between 
preceding  gastric  intestinal  disturbances  and  typhoid  fever.  We 
were  unanimously  of  the  opinion,  which  seems  to  be  quite  generally 
held,  that  acute  diseases  of  the  gastro-intestinal  tract  render  the  indi- 
vidual more  susceptible  to  subsequent  infection  with  typhoid  fever. 
However,  our  studies  have  forced  us  to  come  to  the  following  conclu- 
sions concerning  the  relation  between  typhoid  fever  and  preceding 
temporary  disorders,  including  those  diagnosed  as  diarrhea,  enteritis, 
gastro-enteritis,  gastro-duodenitis,  intestinal  catarrh,  gastro-intestinal 
catarrh,  gastric  fever,  and  simple  indigestion: 

(1)  The  temporary  gastro-intestinal  disturbances  of  May  and  June 
had  but  little  if  any  effect  upon  subsequent  infection  with  typhoid 
fever.  We  mean  by  this  that  men  who  are  reported  as  having  such 
temporary  disorders  during  the  time  mentioned  were  found  to  be  no 
less  and  no  more  susceptible  to  subsequent  typhoid  infection. 

(2)  The  temporary  gastro-intestinal  disturbances  of  July  and  August 
apparentlj^  gave  a  certain  degree  of  immunity  against  subsequent 
infection  with  typhoid  fever. 

(.3)  The  majority  of  men  who  developed  typhoid  fever  did  not  report 
at  sick  call  previous  to  the  appearance  of  this  disease. 

(4)  In  a  considerable  per  cent  (a  little  more  than  one-third)  of  the 
cases  which  are  recorded  as  having  been  preceded  hy  some  intestinal 
disturbance,  the  preceding  illness  was  so  closely  followed  by  typhoid 
fever  that  we  must  regard  the  former  as  having  occurred  within  the 
period  of  incubation  of  the  latter. 

In  order  to  show  the  evidence  upon  which  the  above  given  conclu- 
sions are  founded,  we  offer  the  following  statements : 

We  have  investigated  the  medical  history  of  each  of  12,484  men  at 
Chickamauga.  With  the  names  of  these  men  before  us,  we  have 
ascertained  the  complete  medical  history  of  each  one,  so  far  as  the 
regimental  and  hospital  records  show. 

Of  these  12,484  men,  5,237  had  some  intestinal  disturbance.  As  has 
already  been  stated,  the  names  given  to  these  intestinal  disorders  by 
the  surgeons  were  numerous  and  diversified,  but  we  have  included  all 
under  the  general  head  of  intestinal  disorders. 

The  5,237  men  who  had  some  intestinal  disorder  furnished  672  cases 
of  typhoid  fever. 

This  shows  a  percentage  of  12.83. 

The  7, 247  men  who  had  no  recorded  intestinal  disturbance  furnished 
2,091  cases  of  typhoid  fever. 

This  shows  a  percentage  of  typhoid  fever  among  these  men  of  28.85, 

These  figures  show  that  the  men  who  had  temporary  intestinal  dis- 
orders furnished  less  than  one-half  as  many  cases  of  typhoid  fever  as 


239 

did  the  men  who  had  no  preceding  intestinal  disorder;  but  the  above- 
mentioned  figures  are  misleading  because  in  265  of  the  672  cases  of 
typhoid  fever  that  occurred  among  men  who  had  had  some  intestinal 
disorder,  the  recorded  intestinal  disorder  is  so  closely  connected  with 
the  subsequent  typhoid  fever  that  it  must  be  regarded  as  a  part  of 
the  prodroma  of  tj^phoid  fever. 

A  corrected  statement  would  read  as  follows. 

Four  thousand  nine  hundred  and  seventy-two  men  who  had  had 
some  preceding  intestinal  disorder  furnished  407  cases  of  typhoid 
fever. 

In  other  words,  the  percentage  of  typhoid  fever  among  the  men  who 
had  had  temporary  intestinal  disorder  was  8.18. 

Seven  thousand  five  hundred  and  twelve  men  who  had  had  no  pre- 
ceding intestinal  disorder  furnished  2,356  cases  of  typhoid  fever. 

In  other  words,  the  percentage  of  tj^hoid  fever  among  the  men  who 
had  had  no  intestinal  disorder  was  31.36. 

The  facts  might  be  stated  in  another  way  as  follows : 

Among  2,763  cases  of  typhoid  fever  2,356  were  not  preceded  by  any 
intestinal  disorder. 

In  other  words,  the  percentage  of  cases  of  typhoid  fever  which  were 
not  preceded  by  anj^  intestinal  disorder  was  85.27. 

*  *  *  *  *  *  * 

Respectfully  submitted. 

Walter  Reed, 

Major  and  Surgeon,  U.  S.  A. 
Victor  C.  Vaughan, 
Major  and  Division  Surgeon,  U.  S.  V. 

Edvtard  O.  Shakespeare, 
Major  and  Brigade  Surgeon,  U.  S.  V. 

O 


K^ 


DUE  DATE 

OCT  1 

3  1993    ui 

:t  3  1 199. 

L 

K 

M?-"?  199 

^   M*R  2  )■'■ 

^rjiP>fs-' 

*9        /      177 

201-6503 

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